olumbia  Q^nibergil 

in  ti)t  Citp  of  ^t\ii  Borfe 

^ci)ool  of  Bental  anb  0val  ^urgerp 


Eeferente  i^ibrarp 


6: 


0 


DISEASES    OF 
THE     THYEOID     GLAND 


AXD 


THEIR   SURGICAL   TREATMENT 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofthyroiOOberr 


DISEASES  OF 

THE  THYROID  GLAND 


AND 


THEIR  SURGICAL  TREATMENT 


BY 

JAMES    BERRY 

B.^.hosv.,  F.E.C.S. 

SL'KGEOX  TO  THE  ROYAL  FREE  HOSPIT.Ai  AND  LECTURER   OX  SURGERY 

AT    THE    LONDON    (ROYAL   FREE    HOSPITAL)    SCHOOL 

OF   aiEDICIXE   FOR   TTOMEJi  ;    SURGEON    TO    THE 

ALEXANDRA    HOSPITAL   FOR    HIP   DISEASE 


PHILADELPHIA 

P.    BLAKISTON'S   SON   &   CO. 

1012   WALNUT   STREET 
1901 


Printed  in  Great  Britain 


TO 


IX    GRATEFUL    AND    AFFECTIONATE 


RECOGNITION    OF    MUCH    VALUABLE    HELP 


IN    n>    PREPARATION 


THIS    BOOK    IS    DEDICATED 


PREFACE. 


This  book  is  based  upon  the  Essay  to  which  the  Jacksoiiian 
Prize  of  the  Royal  College  of  Surgeons  for  1886  was  awarded. 
The  essay  in  its  original  form  was  never  published  because  I  felt 
that  at  that  time  I  had  had  so  little  personal  experience  of 
thyroid  operative  surgery,  that  it  was  undesirable  to  commit 
my  observations  to  print.  During  the  last  fourteen  years, 
however,  I  have  enjoyed  unusual  facilities  for  the  study  of  this 
branch  of  surgery,  and  much  of  what  was  written-  in  the 
original  essay  has  been  entirely  rewritten,  by  the  light  of 
farther  experience. 

The  Hunterian  Lectures,  which  I  had  the  honour  of  deliver- 
ing at  the  Royal  College  of  Surgeons  in  1891,  have  also  been 
incorporated  in  the  present  work. 

I  am  fully  aware  of  the  many  imperfections  in,  and  omissions 
from,  the  book,  and  should  have  liked  to  wait  for  further  ex- 
perience before  publishing  it.  But  further  waiting  seems 
undesirable,  as  there  would  always  be  something  wanting, 
something  new  to  be  added. 

I  trust  that  those  who  read  the  book  will  deal  gently  with  it, 
and  remember  that  it  is  an  honest  attempt  to  set  forth  as  clearly 
and  concisely  as  possible  what  is  known  by  myself  and  others 
about  a  difficult  and  somewhat  obscure  branch  of  surgery. 

I  have  to  thank  numerous  friends  for  the  help  they  have 
afforded  me ;  some  by  sending  cases  for  treatment,  or  for 
examination,  others  by  supplying  local  information  about  the 
distribution  of  endemic  goitre. 

The  illustrations  are  mainly  from  my  own  photographs, 
supplemented  by  some  others  taken  by  friends.     To  Mr.  Charles 


viii  PRP^FACE. 

Cosens  I  am  especially  indebted  for  all  the  micro-photographs, 
and  for  much  invaluable  help  in  photography.  The  drawings 
are  mainly  by  Miss  G.  Bulkeley-Johnson,  who  has  bestowed  an 
amount  of  care  and  attention  upon  them  for  which  I  am  most 
grateful.  A  few  are  from  the  skilful  pencil  of  Dr.  Ethel 
Vaughan  ;  for  a  very  few  I  am  myself  responsible.  The  patients 
from  whom  the  photographs  have  been  taken  (excepting  those 
shown  in  Figs.  15  and  83)  have  all  been  under  my  own  observa- 
tion, ana  most  of  them  have  been  under  my  own  care. 

The  blocks  (wdth  the  exception  of  those  from  which  Figs.  85, 
111  and  112  have  been  taken),  have  been  prepared  by  Messrs. 
Godart  of  Maiden  Lane,  Strand. 

Several  of  the  illustrations  have  appeared  elsewhere,  illus- 
trating papers  contributed  by  myself  to  the  British  Medical 
Journal,  PolycVmic  Journal,  Tranmctions  of  the  Pathological 
Society,  and  St.  Bartholomew's  Hospital  Reports,  and  for  per- 
mission to  use  these  I  have  to  express  my  thanks. 

To  Mr.  Ernest  Shaw  I  am  indebted  for  much  help  in  the 
preparation  of  microscopic  sections. 

My  best  thanks  are  due  to  my  friends  Mr.  Anthony  Bowlby 
and  Mr.  Edmund  Roughton  for  much  valuable  advice,  and  for 
the  trouble  they  have  taken  in  revising  the  proof  sheets. 

21  WiMPOLE  St.,  London,  W. 
Feb.   1901. 


CONTENTS. 


CHAPTER    I. 

ANATOMY. 

Lateral  lobes — Upper  and  lower  horns — Isthmus — Pyramid — Relations — 
Arteries  — Veins — Lymphatics — Nerves — Internal  structure — Accessory 
thyroids — Parathyroids       ........     Pp.  1-13 


CHAPTER   II. 

CONGENITAL   AFFECTIONS. 

Congenital  malformations — Complete  absence — Absence  of  one  lobe — Absence 
of  isthmus — Accessory  thyroids — Congenital  goitre  in  man,  in  lower 
animals — Treatment  of  congenital  goitre  .         .         .         .  Pp.  14-19 


CHAPTER   III. 

ATROPHY   AND   HYPERTROPHY. 

Atrophy:  in  old  age  —  Myxoedema — Treatment  —  Cretinism  —  Sporadic  and 
endemic — Fatty  tumours  of  cretinism.  Hypertrophy  :  Compensatory — 
Physiological — Relation  to  menstruation — Pregnancy — Puberty — Thyroid 
of  stout  and  thin  persons  .......  Pp.  20—35 


CHAPTER   IV. 

GOITRE   AND    ITS    VARIETIES. 

Meaning  of  the  word  goitre — Parenchymatous — Cystic — Fibrous — Adenoma- 
tous (foetal  and  cystic  adenomata) — Malignant — Exophthalmic — Hfemor- 
rhagic — Colloid — ' '  Vascular '" — Endemic — Sporadic — Epidemic — Acute — 
Suffocating — Substernal — Intra-thoracic — Retro-tracheal — Retro-i  esopha- 
geal    ...........  Pp.  36-48 


x  contents. 

c'haptj:r  v. 

ENDEMIC   GOITRE-CAL'SATION   AND   DISTRIBUriON. 

Alleged  causes — Climate — Physical  configuration  of  soil — ''  Want  of  air  and 
sunshine "'  theory — Erroneous  nature  of — Relation  to  geology — Geological 
and  geographical  distribution  in  England — Relation  to  calcareous  rocks 
and  waters  derived  from  them — Lime — Magnesia — Iron — Organic  impuri- 
ties— Epidemic  goitre — Goitre  wells — Artificial  production  of  goitre — 
Goitre  in  lower  animals — Habits  of  life,  exertion,  strain,  &c. — Heredity — 
Conclusions Pp.  49-71 

CHAPTER   VI. 

SYMPTOMS   AND   DIAGNOSIS   OF    THYROID   ENLARGEMENTS 
—PHYSICAL   SIGNS. 

Mobility — Shape — Size — Position  with  regard  to  muscles,  great  vessels, 
sternum — Pulsation — Diagnosis  from  aneurism — Consistence — Pressure 
effects,  on  veins,  recurrent  laryngeal  nerve,  sympathetic,  cervical  and 
brachial  plexuses,  larynx  and  trachea,  ctsophagus  and  pharynx 

Pp.  7-.^-104 

CHAPTER   Vn. 

THE   DYSPNCEA  CAUSED   BY   GOITRE. 

Frequency  and  importance — Pressure  upon  trachea — Lateral  compression^ 
Scabbard-shaped  trachea — Effect  on  trachea  of  bilateral  goitre,  unilateral, 
median — Softening  of  tracheal  wall — Pressure  upon  recurrent  nerves — 
Direct  extension  to  trachea — Rupture  of  cyst  or  abscess — CEdema  of 
glottis — Swelling  of  tracheal  mucous  membrane— Varieties  of  goitre 
most  likely  to  cause  dyspntea ;  relation  to  age  and  sex — Danger  of 
bilateral  goitre  of  puberty  and  of  deeply  seated  goitres — Table  of  cases  of 
goitre  causing  death  by  suffocation    .....         Pp.  105-129 

CHAPTER   Vni. 

INFLAMMATION,. 

Acute  idiopathic  inflammation — Typhoid  fever — Rheumatism — Pyasmia — Trau- 
matic inflammation — Symptoms — Results  of  suppuration — Diagnosis — 
Treatment.  Chronic  inflammation  —  Primary  chronic  inflammation  — 
Diagnosis  from  malignant  disease — Treatment  .         .         .         Pp.  130-14.5 

CHAPTER   IX. 

TUBERCLE   AND   SYPHILIS. 

Tubercle  :  Miliary — Usually  secondary — Caseating — Rarity  of— Extirpation  of 
tuberculous  goitre.  Syphilis  :  frequently  affects  thyroid  in  form  of  slight 
general  enlargement — Gummata  rare — Congenital  syphilis       Pp.  146-1.51 


CONTENTS.  xi 

CHAPTER   X. 

CYSTIC    DISEASE. 

Frequency — Age — Modes  of  origin — Transition  of  adenomata  into  cysts — 
Single  and  multiple  cysts — Hsemorrhagic  cysts — Structure  of  cyst  wall — 
Of  contents — Vacuolation  of  colloid — Intra-cystic  growths — Malignant 
nature  of — False  intra-cystic  growths        ....         Pp.  152-164 

CHAPTER   XI. 

HYDATIDS. 

Karity  of — Museum  specimen — Age — Sex — Absorption  of  gland  by  pressure — 
Symptoms — Suppuration — Diagnosis — Urticaria — Eupture  into  trachea — 
Treatment — Table  of  cases Pp.  165-175 

CHAPTER   Xn. 

EXOPHTHALMIC  GOITKE  AND  ITS  TEEATMENT. 
(GEAVES'S  DISEASE;  BASEDOW'S  DISEASE.) 

Age — Sex — Pathology — Morbid  anatomy — Characteristic  appearance  on  sec- 
tion—  Microscopical  appearance — Absence  of  accumulated  colloid  — 
Secondary  changes — Exophthalmos — Cause  of — Enlargement  of  thymus — 
Symptoms  and  Diagnosis — "Formes  frustes  " — Treatment  :  Medical,  Sur- 
gical— Operations  upon  the  thyroid — Extirpation — Eesults — Exothyropexy 
— Operation  upon  vessels — Operation  upon  sympathetic — Section — Eesec- 
tion  —  Unilateral  —  Bilateral  —  Eesults  —  Mortality — Prognosis  without 
operation — Conclusions      .......         Pp.  176-196 

CHAPTER  Xin. 

MALIGNANT   DISEASE  AND   ITS   TREATMENT. 

Affects  both  normal  and  goitrous  thyroid — Age — Sex — Varieties — Sarcoma 
and  carcinoma — Eelative  frequency — Symptoms  and  diagnosis — Infiltra- 
tion of  neighbouring  parts — Skin  rarely  involved — Duration  of  the  disease 
— Mode  of  death — Unusual  forms  of  malignant  disease — "  Malignant 
adenoma  " — Papuliferous  cyst — Treatment — Extirpation — Difficulties  and 
dangers — Of  ten  incomplete — Eesults  of  operations — Recurrence — Statistics 
— Slowly  growing  forms — Palliative  treatment — Partial  removal — Simple 
incision — Tracheotomy — Difficulties — Dangers  of  sepsis — Treatment  of 
dysphagia- and  pain — Conclusions       .         .         .         .         .         Pp.  197-226 

CHAPTER   XIV. 

TEEATMENT   OF   INXOCEXT   GOITEE— NON-OPERATIVE. 

General — Eemoval  of  cause — Medicinal — Iodine — Thyroid  extract — Other 
drugs — Cases  suitable  for — Local — External  applications — Indian  method 

Pp.  227-230 


xii  COXTKNTS. 

CHAPTER   XV. 

TREATMENT  BY  TAPPING— INJECTION— INCISION— SETOX— 
LIGATURE   OF   THYROID   ARTERIES— EXOTHYROPEXY. 

Tapping :  For  cystic  goitre — Occasionally  cures — Risks  of — Hiemorrhage. 
Injection  :  Of  parenchymatous  goitre — Directions — Risks — Fatal  cases — - 
Of  cystic  goitre — Directions — Risks — Results.  Incision  :  Rarely  desirable 
— Cases  suitable  for.  Seton  :  Dangers  of.  Ligature  of  thyroid  ar«^^eries: 
Historical — Recent  revival — Methods  of  operating.  Exothyropexy  : 
Historical — Objects  of — Objections — Methods  of  operating — Results — 
Complications— Mortality Pp.  231-249 

CHAPTER   XVI. 

DIYISIOX   OR   RESECTION   OF   THE   THYROID   ISTHMUS. 

Early  cases — ''Atrophy"  of  later.il  lobes — Explanation  of — Dyspntta  not  due 
to  backward  pressure  of  isthmus — Results  of  the  operation — Re-appear- 
ance of  goitre — Conclusions        .         .         .         .         .         .        Pp.  250-256 

CHAPTER   XVn. 

TREATMENT   BY   EXTIRPATION   (THYROIDECTOMY). 

Difference  between  extirpation  and  enucleation — Partial  extirpation — Pre- 
paration of  patient — Question  of  general  anaesthetic — Local  anesthetic — 
Position  of  patient — Skin  incision  :  oblique,  vertical,  transverse — Treat- 
ment of  infra-hyoid  muscles — Recognition  of  gland — Isolation  of  lobe — 
Ligature  of  thyroid  vessels — Veins  often  thin  and  liable  to  tear — Treat- 
ment of  inferior  thyroid  artery — Avoidance  of  recurrent  nerve — Treatment 
of  isthmus — Arrest  of  haemorrhage — Cleansing  of  wound — Asepsis  better 
than  antisepsis — Suture  of  muscles,  of  skin — Question  of  drainage — 
Dressings — Use  of  sponge — Fixation  of  head  and  neck — Position  of  patient 
after  operation — After-treatment — Convalescence      .         .         Pp.  257-274 

CHAPTER   XVHI. 

MODIFICATIONS  OF   EXTIRPATION- RESECTION- RESECTIOX- 
EXTIRPATION— AMPUTATION. 

Mikulicz's  resection — Description — Results — Kocher's  resection-extn-pation — 
Comparison  of  the  two  operations — Advantages  over  other  operations — 
Amputation Pp.  275-279 

CHAPTER    XIX. 

TREATMENT   BY   INTRA-GLANDULAR   ENUCLEATION   AND 
ITS   MODIFICATIONS. 

Intra-glandular  enucleation  :  History — Cases  suitable  for — Description  of 
operation — Htemorrhage — Suture  of  gland.    Resection-enucleation  ;  Cases 


COXTEXTS.  xiii 

suitable  for — Description — Advantages  and  disadvantages.  Intra-capsular 
enucleation.  ■'Bloodless''  enucleation.  •' Evidement '' :  Cases  suitable 
for      . Pp.  2S0-294 

CHAPTER   XX. 

COilPLICATIOXS    OF    OPEEATIONS   FOR    EEMOYAL    OF 
XOX-ilALIGXANT   GOITEE. 

I.  Accidents  occurring  during  the  operation  :  Sudden  death — Causes  of — 
Cases — Importance  of  avoiding  tracheotomv,  if  possible — Primary  haemor- 
rhage in  extirpation,  in  enucleation  —  Injury  to  nerves  —  Recurrent 
laryngeal  nerve,  sympathetic,  vagus — Injury  to  trachea,  pleura,  pharynx 
and  oesophagus.  II.  Complications  occurring  shortly  after  the  operation  : 
Secondary  haemorrhage — Recurrent  liaemorrhage — Sepsis — Treatment  of — 
Rapid  pulse  with  restlessness — Causes  of — Late  compression  of  recurrent 
nerve  by  scar — Tetany        .......         Pp.  295—317 

CHAPTER    XXI. 

REMOTE    COjIPLICATIOXS— CACHEXIA   STEOIIPEIYA. 

Historical — Reverdin  and  Kocher — Horsley's  experiments — Early  observation 
of  Paul  Sick — Symptoms — Relation  to  complete  removal,  to  partial 
removal  —  Hypertrophy  after  partial  removal  —  Treatment  of  cachexia 
strumipriva  .         .         .         .         .         .  .         -         .        Pp.  -315-327 

CHAPTER    XXII. 
RESULTS   OF   OPERATIONS. 

Gradual  improvement — Mortality  after  removal  of  innocent  goitre — Liebrecht's 
and  Reverdin's  statistics — Mortality  after  partial  extirpation,  after 
enucleation — Complicated  cases — Author's  results — Causes  of  death — 
Relief  from  dyspnosa — Question  of  recurrence  after  extirpation,  after 
enucleation — EfEects  upon  voice — Effect  upon  general  health — Healing  of 
the  wound — Scar. 

Appendix  :  Table  of  the  last  100  operations  performed  by  the  author 
for  removal  of  goitre  .......        Pp.  32S-3.53 


Index Pp.  3.54-367 


LIST   OF   ILLUSTRATIONS. 


fig: 
1, 

3. 
4. 


9, 
12. 
13. 
14. 
15, 
17. 
18. 
19, 
21. 
22, 
24, 
26. 
27. 
28. 
29. 
30. 
31. 
32. 
33. 
34, 
37. 
38. 
39, 
41. 
42. 
43, 
4.5. 
46, 


2.   Parenchymatous  goitre  showing  relation  to  larynx,  trachea,  and 

thyroid  vessels          .         .         .         .         .         .         .         .         .         .  2,  3 

Pyramid,  not  enlarged         .........  4 

Pyramid,  enlarged,  in  parenchymatous  goitre     .....  5 

Variations  in  form  and  size  of  human  thyroid  (from  Marshall)            .  6,  7 

Diagram  to  show  suspensory  ligament         ......  8 

Diagram  of  thyroid  veins  (from  Kocher)     ......  11 

Accessory  thyroids,  situation  of           .......  12 

10,  11.  Congenital  goitres    .         .         .         .         .         .         .         .  17,  18 

Thyroid  gland  of  myx<pdema      ........  22 

Microscopical  appearances  of  the  same        ......  23 

Clinical  features  of  myxa^dema  ........  23 

16.  Myxtedema  before  and  after  thyroid  treatment      ....  24 

Non-goitrous  cretinism         .........  25 

Goitrous  cretinism       .                                     .         .                            .          .  29 

20.  Re-enlargement  of  thyroid  after  partial  removal  .  .  32,  33 

Parenchymatous  goitre  in  a  man          .......  37 

23.  Parenchymatous  goitre  in  a  woman        .....  38,  39 

25.  Bilateral  goitre,  mainly  parenchymatous        .....  40 

Section  of  parenchymatous  goitre       .......  41 

Goitre  with  multiple  adenomata           .......  42 

Large  solid  adenoma  ..........  43 

Foetal  thyroid  (normal)         .........  44 

Ftttal  adenoma    ...........  45 

Cystic  adenoma  .........  45 

Goitre  with  adenomata  and  fibrosis     .......  46 

"  Hsemorrhagic "  thyroid  cyst      ........  47 

35,  36.  Large  parenchymatous  goitre,  treated  by  extirpation         77,  78,  79 

The  same  patient  after  operation         .......  80 

Bilateral  goitre  causing  much  dyspnoea       ......  81 

40.  Swiss  peasant  with  large  goitre     .......  82 

Thyroid  tumour  in  unusual  situation            ...          ...  84 

Small  prominent  thyroid  cyst      ........  85 

44.  Pendulous  adenoma        .........  86 

Goitre  showing  prolongation  into  thorax    ......  90 

47.  Goitre  of  large  size        .........  94 


LIST    OF    ILLUSTRATIONS. 


XV 


FIGS.  PAGES 

48-  Calcareous  material  from  an  old  goitre      ......       96 

49,  .50.  Parenchymatous  goitre  before  extirpation  .....       98 

51.  The  same  patient,  after  operation      ......     100 

52,  53,  54.  Tracheas  showing  deformity  produced  by  goitre   .  .110 
55,  56.  Large  adenoma  simulating  parenchymatous  goitre                -  111 

57.  The  same  patient,  a  week  after  enucleation       .....     112 

58.  Diagrams  of  tracheal  rings  showing  flattening  produced  by  goitre  .     113 

59.  Primary  chronic  inflammation  of  the  thyroid    ....     141 

60.  61,  62.  Specimens  illustrating  the  transformation  of  a  solid  adenoma 
15 


78. 
79. 
80. 
81. 
82. 


87, 
89. 
90. 


200, 


into  a  cyst       .         . 

63.  Thyroid  cyst  with  remains  of  adenoma 

64.  Cystic  adenoma  ..... 

65.  "Woman  with  large  thyroid  cyst 

66.  The  same,  a  week  after  enucleation  . 
67-  Large  thyroid  cyst     ..... 

68.  Parenchymatous  goitre  showing  masses  of  colloid 

69.  Parenchymatous  goitre  with  cysts 

70.  Exophthalmic  goitre  (Graves's  disease) 

71.  Thyroid  and  thymus  from  a  case  of  exophthalmic  goitre 

72.  The  same,  from  behind      .... 

73.  Microscopical  section  of  parenchymatous  goitre 

74.  Microscopical  section  of  exophthalmic  goitre    . 

75.  76.  Spindle-celled  sarcoma  of  thyroid 
77.  Spindle-celled  sarcoma  in  a  young  man 

Museum  specimen  of  sarcoma  of  thyroid  . 
Microscopical  section  of  carcinoma  of  thyroid 
Museum  specimen  of  malignant  thyroid  . 
Sarcoma  of  thyroid  causing  paralysis  of  sympathetic 
L'nusually  large  malignant  tumour  of  thyroid   . 
83,  84.  Papuliferous  cystic  carcinoma  of  thyroid 

85.  Koenig's  tracheotomy  tube         ..... 

86.  Fistula  after  injection  of  goitre 
58.  Large  solid  adenoma,  before  operation 
The  same  patient,  after  operation     ... 
Tumour  removed  from  the  preceding         ... 

91.  92.  Solid  adenoma  in  middle  line  of  neck,  before  operation 

93.  The  same  patient  after  operation,  showing  transverse  scar 

94.  Parenchymatous  goitre  before  extirpation 

95.  The  same  patient,  six  dajs  after  operation 

96.  Transverse  scar  after  enucleation  of  cystic  adenoma 

97.  Right  lobe  of  thyroid  showing  a  cystic  adenoma 

98.  Goitre  scoops     ....... 

99.  100.  Patient  before  and  after  enucleation  of  a  solid  adenoma  . 

101.  Large  solid  adenoma  simulating  a  bilateral  goitre,  before  operation 

102.  The  same,  one  week  after  operation  ..... 

103.  Cystic  adenoma  before  enucleation  ...... 

104.  The  same  patient,  one  week  after  enucleation,  oblique  scar 

105.  The  same,  a  rear  later       ........ 


154 

155 

155 

156 

157 

158 

162 

163 

177 

179 

180 

181 

181 

,  201 

.     202 

.     203 

.     204 

.     206 

.     208 

.     209 

210,  211 

.     225 

.     239 

.     261 

.     263 

.     203 

.     265 

.     266 

.     272 


281 
283 
284 
285 
287 
287 
289 
289 
290 


XVI 


LIST   OF    ILLUSTRATIONS. 


KIGS. 

106,  107-  Diagrams  illustrating  resection-enucleation 
lOS.  Cachexia  strumipriva  (operative  myxa'dema) 

109.  Another  case  of  cachexia  strumipriva        .... 

110.  Re-enlargement  of  thyroid  after  almost  complete  removal 

111.  Bilateral  mainly  adenomatous  goitre  before  operation 

112.  The  same  patient,  twelve  days  later,  showing  oblique  scar 

113.  Tumour  removed  from  the  iDreceding 

114.  115.  Solid  adenoma,  before  enucleation 

116.  A  good  transverse  scar  after  an  enucleation 

117.  A  bad  oblique  scar  after  an  enucleation    . 

118.  A  good  vertical  scar  after  an  extirpation 

119.  120.  Bilateral  goitre  causing  much  dyspna^a,  before  ope:ation 
121.  Deeply  depressed  and  ugly  scar  after  extensive  bilateral  operation 

upon  preceding        ....... 


I'.\GES 

291 
319 
321 
326 
332 
332 
333 
335 
337 
338 
339 
340 

341 


CHAPTER   I. 

ANATOMY. 

Lateral  lobes— Upper  and  lower  horns — Isthmus — Pyi-amid — Eelations 
— Arteries — Veins — Lymphatics — Nerves — -Internal  structure— Acces- 
sory thiToids — ParatliAi'oids. 

The  thyroid  gland  in  the  human  subject  consists  of  two  lateral 
lobes  united  by  an  intervening  portion  named  the  isthmus.  The 
right  lobe  is  usually  slightly  larger  than  the  left.  The  weight 
of  the  whole  gland  is  about  one  ounce.  The  general  shape  of 
the  ffland  bears  some  resemblance  to  that  of  a  horseshoe,  the 
concayity  being  directed  upwards. 

Each  lateral  lobe  is  roughly  pyriform  in  shape.  The  upper 
end  is  the  smaller  ;  it  is  directed  upwards  and  slightly  backwards 
and  usually  extends  as  high  as  the  middle  of  the  posterior 
border  of  the  thyroid  cartilage  ;  sometimes  it  extends  as  high  as 
the  upper  border.  The  lower  end  is  broader  and  more  rounded. 
It  commonlv  extends  as  low  as  the  sixth  ring  of  the  trachea.  Its 
relation  to  the  upper  border  of  the  sternum  varies  according  to 
the  position  of  the  head  and  the  length  of  the  neck.  When  the 
head  is  extended  the  lower  part  of  the  gland  is  from  half  an 
inch  to  an  inch  above  the  upper  border  of  the  sternum.  During 
flexion  of  the  head  it  descends  down  to  or  below  this  level. 

The  upper  horn  of  the  gland  is  that  part  of  the  lateral  lobe 
which  lies  above  the  level  of  the  upper  border  of  the  isthmus. 
Similarly  the  lower  liorn  is  that  part  which  lies  below  the  lower 
border  of  the  isthmus  ;  it  is  usually  much  smaller  than  the  upper 
horn  ;  frequently  it  is  altogether  absent. 

The  isthmus  varies  greatly  in  size  in  different  subjects.  In 
rare  cases  it  is  entirely  absent,  the  two  lateral  lobes  being  quite 
separate  from  each  other.  This  is  the  normal  condition  in  many 
of  the  lower  animals.     It  may,  on  the  other  hand,  be  thick  and 


2  THE    THYROID    GLAND. 

broad,  covering  several  rings  of  the  trachea  and  part  of  the 
larynx.     Between  these  two  extremes  every  variety  in  the  size 


Tigs,  l  and  2.— An  Enlarged  Tliyi-oid  Glaud  (Parenchymatous 
Goitre)  showing  the  manner  in  which  it  nsiially  produces  dyspnoea 
by  pressing-  upon  tlie  trachea.  The  gland  has  preserved  its  natural 
shape,  but  is  uniformly  and  considerably  enlarged.  The  trachea  is 
greatly  narrowed  laterally  at  a  point  one  inch  below  the  larynx.     The 


and  shape  of  the  isthmus  may  be  found.      The  isthmus  usually 
covers  two  or  more  of  the  first  four  rings  of  the  trachea. 


ANATOMY. 


The  pyramid  of  Lalouette,  often  known  as  the  middle  lobe, 
is  an  elongated  portion  of  gland  which,  when  present,*  extends 


superior  and  inferior  thyroid  arturie^  and  theii-  relative  sizes  are  vreM 
seen  (the  left  superior  artery  is.  however,  abnormally  smaU).  (From 
a  boy  aged  14,  who  died  of  dyspnoea  produced  by  the  goitre.  St. 
Bait.  Hosp.Mus.  No.  2  310.     N:ir.  size.)     (See  also  pp.  108,  127.) 

from  the  isthmus  upwards  in  front  of  the  larynx  for  a  variable 

*  Marshall  found  a  pjTamid  in  43  per  cent,  of  the  sixty.cases  examined  by 
him. 


THE   THYROID    (iLAXD. 


distance.  Sometimes  it  reaches  tlie  hyoid  bone  ;  more  often  it 
covers  only  the  lower  part  of  the  larvnx.  From  its  tip  a  band 
of  connective-tissue  frequently  extends  upwards  to  the  back  of 

the  hyoid  bone.  Usu- 
ally the  pyramid  is 
present  on  one  side 
only,  most  connnonly 
the  left.  Rarelv  two 
jiyramids  are  present, 
in  A\hich  case  one  at 
least  will  be  very 
small.  In  Fig.  3  a 
pyramid  is  seen  on  the 
left  side,  extending 
from  the  junction  of 
the  isthmus  and  left 
upper  horn  upwards 
to  the  hyoid  bone. 
The  pvramid  becomes 
enlarged  like  the  rest 
of  the  thyroid  gland 
when  this  organ  be- 
comes the  seat  of 
general  enlargement. 
It  may  thus,  by  cover- 
ing up  the  crico-thy- 
roid    membrane    and 

Fig.  3.— Laivnx,  Trachea,  Thyroid  Glaud  and  neighbour-  O^^^^^'      parts      Ot      the 

ino-  pirts  showing-  on   the  left  side  the   process    ol  larvnx.     beCOme      a 

glanditlar  tissue  termed  the  pyramid  of  Lalouette.  g^^J.^.^  ^f  considerable 
It  IS  seen  to  extend  from  the  upper  border   of  the 

left  lobe,  near  the  isthmus,  upwards  to   the   hroid  trouble  ill  SUch  Opera- 

bone.     The  right   lobe   of  the  gland  Ls  a  little  en-  -(;ion«    aS    tl'acheotomv 
larg«d  and  contains  a  cyst.     (St.  Bart.  Hosp.  Mus. 

xo.  23UD.)    (Reduced  f.)  for      parenchymatous 

goitre.  (See  Fig.  4.) 
Some  of  the  principal  variations  in  the  form  and  position  of 
the  isthmus  and  pyramid  are  shown  in  Fig.   5   (pp.  6  and  7), 
-which  has  been  taken  from  Dr.  C.  F.  ^Marshall's  paper.* 


*  "Variations  in  the  Form  of  the  TlijToid  Gland  in  Man." — Journ.  of  Anat. 
and  Physiol.,  vol.  xxLs.  p.  23i. 


ANATOMY.  5 

The  hilus  is  a  term  used  to  denote  that  place,  at  the  inner 
and  back  part  of  each  lateral  lobe,  al  which  the  inferior  thyroid 
arterv  enters  the  gland.  Here  the  recurrent  laryngeal  nerve 
comes  into  close  contact  with  the  gland,  lying  in  the  space 
between  it  and  the  trachea  and  oesophagus. 


Fig.  4. — TbTroid  Glaud,  Laiyux,  &c.,  sliowing-  Parencliyinatous 
Goitre.  The  disease  iuvolve.s  the  Tvliole  glaud,  iucludini;- the  pYiMmld. 
The  latter  covers  the  ;iuterior  surfiee  of  the  1:u-tiix,  ;iud  extends  up- 
wards nearly  to  the  hyoid  bone.  The  flgm-e  also  illustrates  the  difficulty 
that  would  be  met  with  in  performing'  tracheotomy  in  cases  iu  which 
the  pyramid  is  enlarged.  (Frota  a  specimen  iu  St.  Bart.  Hosp.  Mus. 
No.  2314c.)     (Reduced  J.) 

Relations. — The  convex  anterior  surface  of  each  lateral 
lobe  is  covered  by  the  sterno-hyoid  and  sterno-thyroid  muscles, 
and  overlapped  by  a  portion  of  the  sterno-mastoid. 

On  the  outer  side  is  the  carotid  arterv,  enclosed  in  its  sheath 
with  the  internal  jugular  vein  and  pneumogastric  nerve.  Pos- 
teriorlv,  in  the   concavitv  formed   by  the  isthmus  and  the  two 


6  THE    THYROID    GLAND. 

lateral  lobes,  lie  the  trachea,  tesophagus,  and  recurrent  laryngeal 
nerves.  Small  ])ortions  of  the  larynx  and  pharynx  are  embraced 
bv  the  upper  horns,  which  lie  on  either  side  of  these  structures. 


c. 


Fig.  5. — Variatiou?  in  ;izu  -.wrX  Form  of  the  Hmnnu 

The  posterior  border  of  each  lateral  lobe  is  in  contact  with 
the  spine  and  pre-vertebral  muscles. 

The  gland  is  invested  by  a  delicate  but  distinct  capsule  of 
connective-tissue.     This    covers    uniformlv    the    anterior    and 


ANATOMY.  7 

lateral  aspects  of  the  organ.  Passing  round  the  side  of  the 
gland  to  its  posterior  surface  this  capsule  then  splits  into  two 
portions.     One  remains  in  contact  with  the  gland  and  invests 


? 


Thyroia  Glaud.     (From  Dr.  C.  F.  3Iarsliairs  paper. i 

its  posterior  surface.  The  other,  the  thicker  of  the  two,  passes 
to  the  posterior  surface  of  the  pharynx  and  oesophagus,  thus 
enclosing  them  with  the  larynx,  trachea  and  thyroid  gland,  in  a 
common  sheath.     This  is  an  anatomical  point  which,  as  will  be 


thp:  thyroid  gland. 


seen  hereafter,  is  of  considerable  importance  in  connection  with 
operations  for  removal  of  the  diseased  gland.  J 

To  the  cricoid  cartilage  the  gland  is  most  firmly  connected 
on  each  side  by  a  band  of  connective-tissue  termed  the  suspensory- 
ligament,  shown  in  the  accompanying  figure*  (Fig.  6).  This 
passes  from  the  inner  and  back  part  of 
the  lateral  lobe  upwards  to  the  cricoid 
cartilage.  Blending  below  with  the 
capsule  of  the  gland,  these  two  bands 
form  the  upper  ends  of  a  kind  of  sling 
in  which  the  organ  is  suspended  and 
by  which  it  is  firmly  fixed  to  the 
larynx. 

When  the  oland  has  undergone  great 
enlargement  and  is  much  increased 
in  weight,  these  ligaments  become  of 
considerable  importance.  They  form 
strong  cords,  supporting  the  tumour, 
which  otherwise,  by  reason  of  its  weight, 
would  tend  to  fall  away  from  the  larynx. 
f  It  should  be  added  that  the  recurrent 
laryngeal  nerve  lies  in  immediate  con- 
tact with  this  ligament  on  its  outer  or 
posterior  surface^ 

When  enlarged  to  a  moderate  extent 
the  gland  also  comes  into  relation 
above  Avith  the  omohyoid  muscle  and 
below  with  the  upper  part  of  the 
sternum  and  the  inner  ends  of  the 
clavicles. 
The  thyroid  gland  has  a  relatively  large 


Fig.  6. — Dinuraiu  to  sIiom-  tlie 
Suspensory  Ligament 
of  the  Thyroid  Ghmil  and  its 
Kelatiou  to  the  Recurveut 
Laiyageal  IN'erve.  L,  sus])eu- 
sory  ligament ;  A'',  recan-ent 
laryngeal  nerve  ;  f,\  right  lobe 
of  thyroid  gland  drawn  for- 
wards ;  C,  crico-arytenoidcns 
posticus  muscle.  (From  a 
sketch  kindly  made  for  me  by 
3Ir.  C.  B.  Lockwood. ) 


Blood-vessels. 

blood  supply. 

The  chief  arteries  are  the  superior  and  inferior  thyroid,  the 
former  derived  from  the  external  carotid,  the  latter  from  the 
thvroid  axis,  a  branch  of  the  first  part  of  the  subclavian. 

The  superior  thyroid  artery  meets  the  gland  at  the  tip  of  its 
upper  horn.     Here  the  artery  frequently  gives  off  a  large  branch 


*  From  my  paper  in  the  Jiyvrn.  of  A //at.  and  PliijxioL,  vol.  xxii.     See  also 
Liicke,  D'lr  Kranhheiten  drr  Scltilddiilte,  187."). 


ANATOMY.  9 

which  passes  down  to  the  back  of  the  gland.  The  artery  then 
continues  its  course  downwards  and  inwards  along  the  inner  and 
anterior  border  of  the  horn  until  it  reaches  the  isthmus  where, 
much  diminished  in  size,  it  forms  an  anastomosis  with  the  corres- 
ponding artery  of  the  opposite  side,  along  the  upper  border  of 
the  isthmus.  In  its  course  it  gives  off,  besides  branches  to  neigh- 
bourino;  organs,  a  series  of  branches  which  run  downwards  over  the 
anterior  surface  of  the  gland.  The  smaller  branches  penetrate 
the  gland  and  anastomose  freelv  with  the  other  thvroid  arteries. 

The  inferior  thyroid  artery,  usually  considerably  larger  than 
the  superior,  runs  at  first  upwards  ;  it  then  turns  abruptly 
inwards,  runs  behind  the  carotid  sheath  and  the  sympathetic 
nerve  and  reaches  the  back  of  the  gland.  Here  it  breaks  up 
into  several  branches,  some  of  which  enter  the  hilus,  while  others 
spread  out  upon  the  posterior  surface  of  the  gland.  The  close 
proximitv  of  the  artery  to  the  recurrent  laryngeal  nerve  is  of 
much  importance.  Usually  the  main  trunk  of  the  artery  passes 
behind  the  nerve ;  sometimes  the  artery  breaks  up  before  reach- 
ing the  nerve  ;  in  this  case  one  or  more  of  the  branches  may 
pass  in  front  of  it.  Much  less  commonly  the  main  trunk  or  all 
its  branches  will  be  found  to  lie  in  front  of  the  nerve. 

The  relation  of  the  inferior  thyroid  arteries  to  the  gland  is 
shown  in  Fio-.  2. 

Occasionallv  the  thvroid  arteries  are  reinforced  by  an  additional 
arterv,  the  thyroidea  ima.  This  when  present  is  usually  derived 
i'rom  the  innominate  arterv.  It  may  come,  however,  from  the 
aorta  or  the  common  carotid,  or  some  other  neighbouring  vessel. 
It  runs  upwards  and  inwards,  and  is  distributed  to  the  lower 
part  of  the  gland. 

All  the  thyroid  arteries  communicate  freely  with  each  other. 
When  one  is  small  or  absent  the  others  are  usually  large  in 
inverse  proportion. 

It  is  worth  noting  that  nearly  all  the  larger  branches  ramify 
on  the  surface  of  the  gland  just  beneath  the  capsule.  Only  the 
smaller  branches  penetrate  to  the  interior. 

The  thyroid  veins  *  form  at  first  a  well-marked  plexus  on  the 

*  The  description  here  given  of  the  thyroid  veins  is  not  quite  the  same  as 
that  given  in  most  English  text-books.  I  have  preferred  to  follow  that  given 
bj'  Kocher. — "Ueber  Ki-opfexstirpation  und  ihre  Folgen  "  :  Langenbeck's --i/r/<. 
/.  Jd'ui.  Chlr.,  vol.  xxix.  p.  260. 


10  THE   THYROID    GLAND. 

surface  of  the  gland  ;  this  plexus  lies  immediately  beneath  the 
thin  delicate  capsule  of  connective-tissue  which  encloses  the 
gland.  At  certain  points  the  veins  penetrate  this  capsule  and 
pass  off  into  neighbouring  trunks.  The  chief  veins  thus  leaving 
the  gland  are  the  following : 

The  superior  thyroid  vein  has  a  course  similar  to  that  of  the 
corresponding  artery  ;  it  leaves  the  apex  of  the  superior  horn  and 
enters  the  internal  jugular  vein  a  little  above  this  level.  The 
superior  thyroid  veins  are  connected  with  each  other  by  a  large 
transverse  branch  running  along  the  upper  border  of  the  isthmus. 

At  the  side  of  the  gland  is  sometimes  found  a  single  vein,  the 
middle  thyroid,  entering  the  internal  jugular  vein  ;  more  often, 
however,  the  place  of  this  vein  is  taken  by  two  others  known  as 
the  superior  and  inferior  accessory  thyroid  veins.  The  superior 
comes  from  the  upper  horn,  a  little  below  the  apex ;  the  inferior 
comes  from  the  lower  and  back  part  of  the  gland ;  both  pass 
transversely  outwards  to  join  the  internal  jugular.  The  arrange- 
ment of  the  veins  which  leave  the  lower  border  of  the  gland 
varies  considerably  in  different  bodies.  From  the  isthmus  and 
inner  side  of  the  inferior  horn  comes  a  vein  ^\■hich  descends  more 
or  less  vertically  near  the  front  of  the  trachea  ;  to  this  Kocher 
gives  the  name  of  thyroidea  ima.  On  the  left  side  it  enters  the 
left  innominate  vein  ;  on  the  right  it  joins  either  the  right  or 
left  innominate  vein.  Frequently  this  vein  is  small  or  absent 
on  one  side  ;  frequently  the  two  veins  unite  to  form  a  single 
large  one,  which  descends  vertically  in  front  of  the  trachea  until 
it  enters  the  left  innominate.  This  single  vein  may  sometimes 
be  regarded  as  an  enlarged  right  thyroidea  ima,  that  of  the 
left  side  being  represented  merely  by  a  small  accessory  vein. 
At  the  lower  and  outer  part  of  the  inferior  horn  there  is  often  a 
small  vein,  the  inferior  thyroid,  which  runs  obliquely  downwai'ds 
to  enter  the  innominate  vein  at  its  commencement. 

When  the  thyroid  gland  is  normal  in  size,  inany  of  these 
veins  may  seem  small  and  unimportant.  But  when  it  is  much 
enlarged  bv  disease,  all  the  veins  become  greatly  enlarged  and 
distended,  and  assume  considerable  importance,  especially  in 
connection  with  operative  procedures.  A  diagram  showing  all 
the  veins  above  described  has  been  reproduced  in  Fig.  T  from 
Kocher's  paper,  by  the  kind  permission  of  the  author. 


ANATOMY. 


11 


Nerves. — These  come  from  the  middle  and  inferior  gangha 
of  the  cervical  sympathetic  and  from  the  inferior  laryngeal  nerve. 
It  is  said  that  a  branch  also  comes  from  the  external  laryngeal 
nerve. 

Lymphatics. — The  lymphatics  pass  chiefly  into  the  glands 
that  lie  in  front  and  at  the  sides  of  the  trachea :  some  pass  also 
into  the  cervical  glands  at  the  sides  of  the  th\Toid  gland.  The 
o'lands  first   affected  in   malia;nant  disease   of  the  thvroid.  for 


Fig.  7. — Diagram  showing  a  common  arraimement  of 
ThTTOld  "Veins.     <  From  Koclier.  i 

example,  are  usually  verv  deeply  seated  behind  the  sternum, 
■where  they  cannot  easily  be  seen  or  felt. 

Structure. — The  thyroid  gland  is  composed  of  a  large 
number  of  small  closed  vesicles  supported  by  a  framework  of 
connective-tissue,  derived  from  and  continuous  ^vith,  the  delicate 
capsule  that  surrounds  the  whole  organ. 

Lvins  between  the  vesicles  are  masses  of  round  cells  which 
are  to  be  regarded  as  undeveloped  vesicles.  They  are  more 
abundant  in  the  voung  than  in  the  old,  and  are  often  with 
difficulty  distinguished  from  cells  of  inflammatory  origin. 


12 


THE   THYROID    GLAND. 


0 


The  vesicles  are  lined  with  cubical  epithelium  and  contain 
the  well-known  colloid  material,  the  exact  use  of  which  is 
unknown.  The  gland  has  no  ducts,  but  the  vesicles  connnunicate 
with  the  lymphatic  vessels  that  ramify  between  them,  and  it  is 
probably  through  the  medium  of  the  lymphatics  that  the  colloid 

secretion  of  the  gland 
reaches  the  general  circu- 
lation. The  existence  of 
colloid  material  in  the  lym- 
phatic vessels  can  easily  be 
demonstrated. 

Accessory  Thyroid 
Glands. — The  term  acces- 
sory thyroid  has  been 
applied  to  isolated  and  de- 
tached massses  of  thyroid 
tissue  that  are  often  found 
lying  near  the  main  gland. 
They  are  analogous  to  the 
accessory  spleens  that  are 
often  found  in  the  neigh- 
bourhood of  the  spleen. 

Accessory  thyroids  are 
most  often  found  in  one 
or  other  of  the  following- 
situations  {see  Fig.  8)  : 

1 .  In  front  of  the  larynx, 
anywhere  between  the 
upper  border  of  the  isth- 
mus and  the  hyoid  bone.  Accessory  thyroids  in  this  position 
may  be  regarded  as  persistent  portions  of  the  pyramid  of 
Lalouette.  They  are  almost  always  connected  below  with 
the  main  gland  and  above  with  the  hyoid  bone  by  bands  of 
connective  tissue. 

2.  Above  and  below  the  superior  and  inferior  horns  respec- 
tively. These  may  be  regarded  as  extensions  of  the  horns  and 
are  usually  connected  with  them  by  bands  of  connective  tissue. 

3.  Near  the  posterior  border  of  the  lateral  lobe,  lying  upon 
the  pharynx  or  oesophagus. 


l^iG.   8. — DiagiMUQ   of   the  Thyroid   Gland  seen 
from  the  front,  showins'  (on  the  left  side  only) 

the  iiositions  in  which  Accessory  Thy- 
roids are  most  commonly  found. 


ANATOMY.  13 

Accessory  masses  of  thyroid  tissue  may  also  be  found  occasion- 
ally in  more  distant  parts,  as  at  the  root  of  the  tongue,  or  even 
within  the  larynx. 

It  is  desirable  that  a  distinction  should  be  made  between  true 
accessory  thyroids  of  congenital  origin,  and  the  encapsuled 
masses  of  thyroid  tissue  which  have  been  extruded  from  the 
gland.  Such  tumours  are  analogous  to  the  pedunculated  sub- 
peritoneal tumours  (fibromyomata)  which  have  been  extruded 
from  the  uterus. 

In  both  cases  the  tumours  are  attached  to  the  main  organ  by 
a  more  or  less  well-defined  pedicle. 

Probably  most  of  the  cases  that  have  been  described  as 
"'tumour  of  an  accessory  thyroid  "  are  really  of  this  nature,  and 
are  not  examples  of  true  accessory  glands. 

Parathyroids  are  very  small  glandular  masses  that  lie  close 
to  the  main  gland,  generally  at  the  back  of  it.  They  'differ 
from  the  accessory  thyroids  in  not  containing  vesicles  filled  with 
colloid,  and  their  function  is  supposed  by  some  to  be  different 
from  that  of  the  thyroid  gland  itself.* 

A  specimen  showing  the  parathyroid  of  a  dog  may  be  seen  in 
the  museum  of  St.  Thomas's  Hospital. f 

*  Much  valuable  information  concerning  parathj-roids  will  "be  found  in  Mr. 
Walter  Edxi:unds's  papers  in  the  Journ.  of  Pathulogy  and  Bacteriology,  1896, 
1898,  1899.  and  1900. 

J  No.  1455a. 


CHAPTER   II. 

CONGENITAL  AFFECTIONS. 

Congenital  malformations — Complete  absence — Absence  of  one  lobe  — 
Absence  of  isthmus —Accessory  thyroids — Congenital  goitre  in  man, 
in  lower  animals — Treatment  of  congenital  goitre. 

Congenital  Malformations. — Congenital  malformations 
of  the  thyroid  are  by  no  means  uncommon.  Most  of  them  are, 
however,  of  little  practical  importance,  provided  that  there 
exists  a  sufficient  quantity  of  healthy  gland  to  carry  on  the 
functions  of  the  organ. 

The  most  serious  and  important  malformation  consists  in 
complete  absence  of  the  gland.  This  condition  is  always 
associated  with  the  most  severe  form  of  cretinism.  {See 
chap,  iii.) 

One  lobe  alone  may  be  completely  absent,  or  present  in  a 
rudimentary  form.  This  condition  may  lead  to  serious  results 
if  the  opposite  healthy  lobe  become  affected  by  atrophy  from 
disease,  or  if  it  be  removed  by  operation  on  account  of  disease. 
In  such  a  case,  the  patient  is  deprived  of  all  functionally  active 
thyroid  gland  and  the  serious  condition  known  as  myxcedema 
or  cachexia  strumipriva  {see  chaps,  iii.  and  xxi.)  will  certainly 
supervene.  There  are  no  means  by  which  the  congenital 
absence  of  one  lobe  can  be  detected  during  life,  except  by  actual 
inspection  during  the  course  of  a  surgical  operation. 

Absence  of  the  thyroid  isthmus  is  occasionally  seen  and 
is  of  importance  chiefly  in  connection  with  the  operation  of 
division  of  the  thyroid  isthmus  for  the  relief  of  dyspnoea.  A 
case  has  been  recorded  in  which  a  surgeon  was  about  to  perform 
this  operation,  but  upon  cutting  down  upon  the  gland,  he  found 
that  there  was  no  isthmus.  He  was  obliged  to  content  himself 
with  merely  laying  bare  the  trachea. 


CONGENITAL   AFFECTIONS.  15 

Accessory  thyroids  form  another  class  of  congenital 
malformations  of  the  gland.  When  enlarged  by  disease  they 
may  form  tumours  which  are  difficult  to  diagnose.  They  have 
sometimes  been  of  the  greatest  service  to  patients  upon  whom 
total  extirpation  of  the  thyroid  gland  has  been  performed.  By 
undergoing  compensatory  hypertrophy  and  assuming  the  func- 
tions of  the  extirpated  gland  they  have  saved  such  patients  from 
cachexia  strumipriva.     (See  Figs.  19  and  20.) 

Congenital  Diseases. — Congenital  enlargement  of  the 
gland  is  frequently  seen  in  districts  where  endemic  goitre  is 
common.  Thus  Demme,  among  642  cases  of  goitre  seen  at  the 
Children's  Hospital  at  Berne,  found  fifty-three  in  which  the 
disease  was  congenital.* 

I  have  myself  seen  several  young  infants  with  congenital  goitre. 
Usually  the    enlargement  is    not  very  great.     It  often  dis- 
appears  spontaneously  in   the   course   of  a  few  months.     The 
mother  of  a  child  with  congenital  goitre  has  usually  herself  a 
goitre. 

In  1894  I  saw  with  Dr.  Eminson  at  Scotter,  Lincolnshire, 
a  male  infant,  aged  six  weeks.  At  birth  a  bilateral  goitre  of 
considerable  size  had  been  noticed,  and  for  the  first  few  days 
dyspnoea  was  so  marked  that  it  was  feared  the  child  would  die. 
After  about  a  fortnight  the  dyspnoea  and  stridor  gradually 
subsided  and  the  goitre  became  much  smaller. 

Dr.  J.  G.  Colby,  of  Malton,  has  given  me  notes  of  a  child  born 
with  a  "  good  sized  goitre."  The  mother  had  a  goitre  herself, 
and  said  that  others  of  her  children  had  been  born  with  the 
same  disease. 

Dr.  Ormsby,  of  Slaidburn,  has  recorded  a  similar  case.f 
Sometimes  the  enlargement   is   considerable   and  may  cause 
serious  or  even  fatal  dyspnoea. 

Dr.  Maidlow,  of  Ilminster,  has  informed  me  of  a  case  in  his 
practice  in  which  the  child  died  of  asphyxia  ten  hours  after 
birth.  In  another  case  of  his  the  dyspnoea  was  very  bad  for 
about  thirty  hours,  but  then  subsided,  after  vigorous  treatment 
with  iodine  and  arsenic. 

*  E.  Demme,   "  Krankheiten  der  Schilddriise  "  in  Gerhardt's  ILandhuch  der 
JLindevhranhheiten.  Tubingen,  1878,  vol.  iii.  pt.  ii.  p.  392. 
t  Lancet,  February  25,  1888. 


If)  THE   THYROID    GLAND. 

Dr.  A.  G.  Webster,  of  Golcar,  and  Dr.  T.  R.  Atkinson,  of 
Madeley,  Hereford,  have  also  recorded  cases  of  congenital 
goitre  with  severe  dyspnoea  ending  in  recovery.* 

In  the  Museum  of  the  Royal  College  of  Surgeons  is  a  speci- 
men t  from  a  male  infant  who  died  with  cyanosis  five  days  after 
birth.  The  thyroid  gland  shows  a  general  enlargement.  Its 
structure  to  the  naked  eye  resembles  that  of  the  normal  gland. 
It  weighed  1}  ounces,  and  produced  a  very  obvious  tumour 
during  life.     The  ductus  arteriosus  was  patent. 

In  the  same  museum  is  another  specimen  of  similar  nature. | 
The  gland  is  enlarged  in  all  parts,  and  a  section  shows  a  uniform 
glandular  structure  without  cysts.  There  is  much  compression 
of  trachea  and  oesophagus.  Dr.  Lediard,  who  presented  the 
specimen,  has  given  the  following  description  of  the  case  §  : 

"■  The  infant  from  whom  this  goitre  was  taken  was  born  at  full 
term  and  died  on  the  fifth  day.  The  labour  was  complicated  by 
hydramnios  of  very  decided  proportions.  The  child  was  cyanotic^ 
breathed  with  much  difficulty,  was  unable  to  swallow,  and  when  it 
cried  the  face  became  very  dusky.  The  neck  was  very  bulky  and 
the  middle  and  lateral  portions  of  the  thyroid  gland  were  easily 
felt  to  be  considerably  enlarged.  The  goitre  is  seen  to  surround 
the  windpipe  and  oesophagus  like  a  ring^  whilst  the  latter  more 
especially  is  compressed.  It  is  interesting  to  note  that  the  same 
patient  had  previously  had  hydramnios  Avith  a  nearly  stillborn  child, 
which  had  a  very  large  neck." 

Occasionally  a  congenital  goitre  presents  itself  in  the  form  of 
a  huge  tumour  which  occupies  the  whole  of  the  front  of  the 
neck  from  the  sternum  to  the  chin.  As  a  rule  in  these  cases  the 
child  is  stillborn,  or  dies  soon  after  birth.  A  good  example,  of 
which  Fig.  9  is  a  photograph,  may  be  seen  in  St.  Bartholomev/'s 
Hospital  Museum.  ||  The  child  was  born  at  full  term  as  a  face 
presentation. 

There  is  a  similar  specimen  in  the  museum  of  the  Royal 
College  of  Surgeons,^  In  this  case  the  goitre  presents  a 
markedly  cystic  structure. 

*  Ltnicet.  March  17,  1888.  +  No.  2896. 

X  No.  2896b.  §  Pctfi.  Sue.  Trans.,  xl.  1889,  p.  299. 

II  No.  2319b.     This  case  is,  however,  described  in  the  museum  catalogue  a? 
one  of  spindle-celled  sarcoma. 
f  No.  2896A. 


CONGENITAL   AFFECTIONS. 


Besides  the  above,  I  have  seen  specimens  of  congenital  goitre 
in  several  foreign  museums.*  In  most  of  these  cases  the  latera,! 
lobes  were  not  larger  than  a  walnut,  and  in  some  they  were 
much  smaller.     Most  of  them  presented  a  solid,  almost  homo- 


1 


Fig.  9. — Large  Congenital  Groitre  in  a  stillboi-u  child.  The  coiulitiou 
of  tlie  skin  is  due  to  post-mortem  changes.  (St.  Bart.  Hosp.  Mus.  No. 
2319b.)     (Reduced  f.) 

geneous  appearance,   on  section.     Figs.   10   and    11    are   from 
drawings  of  one  of  the  specimens  in  the  Berne  Museum. 

Congenital  goitre  has  also  been  observed  in  the  lower  animaJs. 
Dr.  Crisp  f  has  recorded  the  case  of  three  lion  cubs  who  were 

*  Prague  Path.  Mus.  (Nos.  3366,  4885b)  ;  Munich  Mus.  of  Path.  Inst. 
(No.  201)  ;  Zurich  Mus.  of  Path.  Inst,  (two  specimens,  each  about  as  large  as  a 
Tangerine  orange)  ;  Berne  Mus.  of  Insel  Hosp.  (four  specimens). 

f  Trans.  Patli.  Soc,  vol.  xv.  p.  260. 

B 


18 


THE    THYROID    GLAND. 


i'lr..  10.- 
lufiuit 


A  Congenital  Goitre  iu  a  Yoxiu^ 

Frout  vifw.     (Nat.  size.) 


all  born  dead  in  a  zoological  garden.     In  each  the  thyroid  was 
enlaroed   to   twenty  times  its  natural   size.     He  refei-s  also  to 
a  similar  case  of  a  lion  cub  which  lived  for  several  months. 
Treatment  of  Congenital  Goitre. — This  will  naturally 

dejiend  upon  the  severity 
of  the  symptoms.  The 
slighter  cases  with  little 
or  no  dyspnoea  require  no 
treatment  at  ail .  In  others 
medicinal  treatment  and 
treatment  of  external  ap- 
plications are  desirable 
just  as  they  are  in  many 
cases  of  parenchymatous 
goitre  in  older  subjects. 
It  is  only  in  cases  of  ex- 
ceptional severity  that  operative  measui-es  become  necessary. 
If  the  symptoms  are  so  severe  as  to  threaten  life,  the  case  must 
be  treated  on  the  same  principles  that  guide  us  in  the  treatment 
of  goitre  in  adults. 

Lugenbiihl,*  who  has  given  a  good  account  of  the  operative 
treatment  of  congenital 
goitre,  describes  a  case  in 
which  Professor  ]Made- 
lung  operated  on  a  child 
two  days  old,  on  account 
of  very  severe  dyspnoea 
caused  by  a  bilateral 
goitre  of  considerable 
size.  A  large  part  of  the 
goitre  was  removed,  but 
tracheotomy     became 

necessary  in  the  course  of  the  operation,  and  death  occurred  on 
the  sixth  day  from  pneumonia.  Lugenbiihl  states  that  he  has  not 
been  able  to  find  in  literature  more  than  three  other  cases  in 
w^hich  operative  interference  was  undertaken  on  account  of  con- 
genital goitre  in  infancy. 


Fig.  11. — The  preceniug-  in  horizontal  section  show- 
ing also  Trachea  and  CEsophagns.  TFrom  a 
specimen  in  the  Path.  Miis.  at  Kerne.)  (Xat.  size.) 


*  '•  Die  Operative  Behandlung  der  Struma  Congenita,"  Beifr.  z.  Idin.  Ch'u 
Tiibingen,  1895,  xiv.  p.  713. 


CONGENITAL  AFFECTIONS.  19 

Malgaigne  operated  on  a  child  aged  three  days,  who  died 
thirty-six  hours  later,  apparently  from  haemorrhage.  Bach 
operated  on  another  case,  but  death  from  asphvxia  followed  in 
the  course  of  a  few  hours.  Both  these  cases  are,  however, 
ancient  ones,  occurring  before  the  davs  of  antiseptic  surgery. 
In  more  recent  times  Schimmelbusch  has  operated  with  success. 
The  patient  was  one  hour  and  a  half  old,  and  was  the  subject  of 
cyanosis  and  extreme  dyspnoea.  The  tumour  was  as  large  as  a 
hen's  egg,  hard  and  nodular,  and  extended  fron)  the  chin  to  the 
sternum.  The  tumour  was  shelled  out  without  anaesthesia,  and 
the  child  made  a  good  recovery.  The  tumour  was  "  solid,  with 
numerous  little  cysts,"  and  contained  cartilage  in  places. 

On  October  11,  1899,  M.  Genevet  *  showed  at  a  meeting  of 
the  Medical  Society  of  Lyons  a  male  infant,  aged  eight  days, 
upon  whom  M.  Pollosson  had  performed,  on  the  day  after  birth, 
the  operation  of  exothyropexy  for  a  suffocating  congenital  goitre. 
Severe  dyspnoea  and  stridor  were  present  before  the  operation. 
The  ultimate  result  is  not  recorded. 

•=  L.jc/i  Mt.'Tiralp.  1899,  p.  303. 


CHAPTER   III. 

ATROPHY  AND  HYPERTROPHY. 

Atrophy:  In  old  age — Myxoedema — Treatment — Cretinism — Spor- 
adic and  endemic — Fatty  tnmonrs  of  Cretinism.  Hypertrophy : 
Compensatory — Physiological — Eelation  to  menstrnation — Pregnancy 
— Puberty — ThjToid  of  stout  and  thin  persons. 

Atrophy. 

Atrophy  of  the  thyroid  gland  may  conveniently  be  discussed 
under  the  following  heads  : 

1.  Old  age. 

2.  Mvxoedema. 

3.  Cretinism. 

1.  Old  Age. — The  thyroid  like  many  other  glands  tends  to 
become  smaller  as  old  age  supervenes.  The  thyroid  gland  of  an 
old  person,  if  not  affected  by  cystic  degeneration,  will  frequently 
be  found  to  be  of  less  than  half  the  w^eight  of  a  normal  adult 
gland. 

In  the  Museum  of  the  Royal  College  of  Surgeons,*  is  a  well- 
marked  example  of  senile  atrophy.  It  was  obtained  by  myself 
from  the  body  of  a  woman  who  died  in  the  Islington  Infirmary, 
at  the  age  of  84,  of  dementia  and  bronchitis,  and  who  had  never 
been  the  subject  of  myxoedema.  The  gland  is  seen  to  be  much 
diminished  in  size  in  all  parts.  It  does  not,  however,  present  the 
shrunken  appearance  that  is  seen  in  the  atrophy  connected  with 
myxoedema.  Each  lobe  of  the  gland,  although  small,  is  rounded, 
firm  and  tolerably  thick. 

Microscopically,  specimens  of  senile  atrophy  present  the 
ordinary  appearances  of  a  gland  that  is  functionally  not  very 
active.  The  colloid  secretion  is  small  in  amount  and  the 
vesicles  and  their  epithelial  cells  are  small  and  ill  formed. 

*  Xo.  2906E. 


ATROPHY   AND    HYPERTROPHY. 


21 


Accordino;  to  Wolfle]-,*  "  the  involution  of  the  human  thyroid 
gland  is  characterised  chiefly  by  sclerosis  of  the  stroma,  its 
change  into  fibrous  tissue,  disappearance  of  the  vesicles  and 
their  change  into  masses  of  atrophied  cells  with  small  nuclei." 

Senile  atrophy  of  the 
thyroid  does  not,  so  far 
as  I  am  aware,  give  rise 
to  any  special  symp- 
toms. 

2.  Myxoedema.  —  In 
this  disease,  atrophy  of 
the  thyroid  gland  pre- 
sents its  most  character- 
istic features. 

In  a  well-marked  case 
(see  Fig.  12)  the  gland 
is  greatlv  reduced  in  size 
and  has  a  flabby,  shrunken 
appearance,  due  to  the 
more  or  less  complete 
absence  of  colloid  secre- 
tion, of  vesicles  and  of 
epithelium.  The  glan- 
dular elements  have 
atrophied,  leaving  only 
the  capsule  and  frame- 
work of  connective- 
tissue.  Microscopically 
{see  Fig.  13),  it  is  found 
to  consist  almost  entirely  of  fibrous  tissue  with  a  few  small 
round  cells.  In  thirteen  cases  in  Avhich  the  pathological  condition 
of  the  gland  wels  investigated  by  the  myxoedema  committee 
of  the  Clinical  Society,!  the  appearances  presented  to  the 
naked  eye  and  under  the  microscoj^e  were  substantially  as  above 
described. 

In  other  unpublished  cases  which  I  have  had  the  opportunity 

.*  "Ueber  die  Ent^^^ckelung  imd  den  Bau  des  Kropfes,"  Avch.f.  Idin.  Chir., 
Berlin,  1883,  xsix. 

X  Tram.  CUn.  Soc,  Lnndon,  1888,  vol.  xxi.  Supplementary  Keport  on. 
MA'xcedema. 


Fig.  12. — Tliyroid  Glaud  li-oui  a  typical  case  of 
Myxoederaa.  Tlie  gland  is  small  and  repre- 
seuted  mainly  by  connective  tissue.  (St.  Bart. 
Hosp.  ilus.  Xo.  2317a.)     (Nat.  size.) 


22  THE   THYROID   GLAND. 

of  investigating   post   mortem,  exactly  the  same  condition  of 

thyroid  was  found.* 

Althouiih  the  above  condition  is  that  which  is  ahnost  always 

found  in  myxoedema,  yet  it  is  but  right  to  mention  that  occasion- 
ally in  this  disease, 
the  thyroid  gland 
appears  clinically 
to  be  enlarged.  Thus 
in  four  of  the  numer- 
ous cases  collected  by 
the  Clinical  Society's 
committee  it  was 
stated  that  the  gland 
was  enlarged,  while 
in  one  it  was  (p.  28) 
"  hard,  as  though 
calcareous."" 

Probably  in  all 
these  cases  however 
there    was    really 

Fig.  13.— Mici-osj()i)U'  Section  of  a  Thyroid  Gland  from      atropliy  of  the  glan- 

a  typicii  case  of  Myxcedema.    The  specimen  shows     (JuJa^j-  elements 

connective   tissue  witli  some  round-celled  infiltration. 

and  rudiments  of  vesicles.     (x_130diam.)  J^t     IS      Universally 

admitted  at  the  pre- 
sent time  that  the  symptoms  of  the  disease  are  due  to  loss  of 
function  of  the  thyroid  gland. 

With  regard  to  the  symptoms  of  myxoedema  it  is  not 
necessai'y  to  say  anything  in  this  book.  They  are  fully  described 
in  all  recent  text-books  on  Medicine,  and  have  been  discussed 
most  exhaustively  in  the  admirable  report  of  the  Clinical 
Society  above  mentioned.  They  concern  the  physician  rather 
than  the  suro-eon. 

The  treatment  of  myxcedema  at  the  present  day  is  both 
simple  and  satisfactory.  It  consists  in  restoring  artificially  to 
the  patient  the  thyroid  secretion,  the  loss  of  which  has  been 
caused  by  atrophy  of  the  gland.  The  original  methods  of 
transplanting   thyroid    tissue    into  the  body  and    of  injecting 

*  Two  of  these  specimens  are  now  in  the  Museuna  of  the  Eoyal  College  of 
Surgeons,  Nos.  2906c  and  29060. 


ATROPHY   AND    HYPERTROPHY. 


23 


th^Toid  secretion  hvpoderniicallv  have  been  given  up  in  favour 
of  the  simpler  method  of  administration  by  the  mouth.  The 
patient  may  be  fed  on  the  thyroid  of  one  of  the  lower  animals, 
either  raw  or  lightly  cooked.  A  more  convenient  method,  and 
the  one  now  almost 
universally  adopted, 
consists  in  the  ad- 
ministration by  the 
mouth  of  one  or  other 
of  the  numerous  ex- 
tracts, tabloids  and 
other  pharmaceutical 
preparations  of  the 
thyroid  gland  sub- 
stance. Care  should 
be  taken  in  adminis- 
tering these  drugs 
that  they  be  given  at 
first  in  small  doses  ; 
otherwise  dangerous 
and  even  fatal  symjD- 
toms  may  occur. 

3.  Cretinism.  — 
Closely  allied  to  myx- 
oedema  and,  like  it, 
due  to  impairment 
or  loss  of  function 
of  the  thyroid,  is  the 
disease  known  as  cre- 
tinism. Myxoedema 
in  its  typical  form  is  however  a  disease  of  adult  life  and  is  due 
to  atrophy  of  the  gland  occurring  after  the  body  has  attained 
its  full  size. 

In  cretinism  the  disease  of  the  thyroid  is  congenital  or  occurs 
in  early  infancy.  The  development  of  the  body  is  consequently 
markedly  affected.  It  is  in  the  altered  development  of  the  body 
and  especially  of  the  bony  skeleton  that  the  chief  difference  lies 
between  cretinism  and  myxoedema. 

The  former  shows  improper  development,  the  latter  degenera- 


FiG.  14. —  A  typical  c:i:^e  of  MyxcEdema.  A 
s'svelling-  similar  to  the  so-called  "  fatrr  tumours  "  of 
cretinism  Ls  seen  in  the  right  snpra-claviciilar  rej^lon. 
(Trom  a  woman  aged  39,  seen  at  Leytoustone  in 
1885.) 


24 


thp:  thyroid  glaxd. 


tion,  of  body  and  mind,  both  diseases  being  due  to  thyroidal 
atrophy. 

That  cretinism  and  endemic  goitre  are  in  some  wav  associated 
is  a  fact  that  has  been  known  for  centuries.  AVherever  goitre  is 
prevalent  as  an  endemic  disease  there  also  will  cretinism  be 
found.*  It  is  plain  that  in  the  vast  majority  of  cases  the  two 
diseases  are  due  to  the  same  cause,  whatever  that  may  be. 

The  direct  connection,  however,  which  exists  between  cretinism 
and  atrophy  of  the  thyroid  gland  was  first  pointed  out  by  jMr. 
Curling.  He  published  two  cases  of  sporadic  cretinism,  in  which, 
on  dissection,  no  trace  of  a  thvroid  could  be  detected. t     Some 


Fig.  15.— a  typical  e-u.-u  of  Myxoederaa.  I'ig.  is.— The  same  patieut 
after  tliree  months  of  thyioitl  treatment.  (Under  the  care  of  Dr. 
Da  vies.     From  photosTaphs  kindly  lent  by  him.  i 

vears  later  Dr.  Hilton  Fagge  laid  before  the  Medical  and  Chi- 
rursical  Society  an  account  of  four  cases  of  cretinism  in  which 
the  thvroid  appeared  to  be  absent. i:  IMore  recently  Dr.  Fletcher 
Beach  showed  to  the  Pathological  Society,  §  two  cases  of  the 
same  disease,  in  neither  of  which  was  there  any  thyroid 
gland. 

Dr.  "William  Robinson  has  recorded  the  case  of  a  cretin  ased 
ten  who  died  in  November  1884.  At  the  post-mortem  examina- 
tion, "  no  trace  of  a  thyroid  gland  was  found." 

The  publication  of  these  and  other  similar  cases  led  to  the 

*  Eeaf-mutism    is    also  frequently  found  in  association   -s\itli  these    two 
diseases. 

t  Med.  Cliir.  Tram.,  vol.  xxxiii.  p.  30.3.  +  Ihul.  vol.  liv.  p.  15.5. 

$  Path.  Soc.  Trans:,  vol.  xxv.  p.  255  and  vol.  xxvii.  p.  31<3. 


ATROPHY   AND    HYPERTROPHY.  25 

belief  that  in  sporadic  cretinism  the  thyroid  gland  was  always 
absent,  but  the  truth  of  this  assertion  was  disproved  by  the 
subsequent  post-mortem  examination  by  Dr.  Hilton  Fagge  of 
one  of  the  four  cases  published  by  him  ten  years  previously.     In 


Fig.  17. — Non-Goitrous  Cretinism,  the  worst  lorm  of  this  disease. 
Showing-  tlie  similarity  between  it  aud  acquired  Myxoedema.  The 
patient  was  a  native  of  Steeple  Astou,  'Wiltshire,  where  she  had  always 
lived.  She  was  25  years  of  age,  but  was  less  intelligeut  than  most 
children  of  three.  Xo  thyi-oid  gland  could  be  felt.  The  mother  had  a 
goitre. 

this  case,  the  first  in  which  he  had  an  opportunity  of  examining 
the  condition  of  the  gland  after  death,  he  found  that  the  thyroid 
was  not  absent  but  that  it  was  actually  enlarged,  being  the  seat 
of  a  distinct  goitre. 

It  must  not  be  supposed  that  in  all  cases  of  cretinism  the 


26  THE   THYROID   GLAND. 

thyroid  gland  is  smaller  than  normal.  On  the  contrary  the 
majority  of  cretins  have  enlarged  thyroid  glands  (see  Fig.  18). 
These  glands  however  are  not  healthy.  They  are  more  or  less 
diseased  and  they  always  contain  an  abnormally  small  amount 
of  functional  gland  tissue. 

In  the  worst  form  of  cretinism,  the  form  that  is  perhaps  the 
most  connnon  in  this  country,  the  atrophy  of  the  gland  is 
extreme.  The  organ  is  either  con^pletely  absent,  or  is  repre- 
sented by  a  mere  rudiment  consisting  chiefly  of  connective-tissue. 
This  form  is  usually  accompanied  by  much  mucoid  degeneration 
of  the  subcutaneous  tissues  and  very  closely  resembles  the 
myxcedema  of  adults. 

In  the  Royal  Free  Hospital  museum  *  is  a  good  specimen  of 
the  extreme  atrophy  of  the  gland  that  is  associated  with  this 
most  severe  form  of  cretinism.  All  that  remains  of  the  gland 
is  a  mere  rudiment  of  connective- tissue. f 

In  Guy's  Hospital  museum  is  another  specimen  j  of  a  thyroid 
gland  from  a  case  of  cretinism.  In  this  case  the  gland  is  some- 
what enlarged  but  has  undergone  much  degeneration. 

Dr.  Arthur  Hanau,  in  a  paper  §  read  before  the  International 
Medical  Congress  at  Berlin  in  1890,  describes  three  specimens  in 
the  Zurich  Pathological  Museum,  obtained  post  mortem  from 
adult  cretins  by  Prof.  Klebs. 

The  following  is  his  description  : 

"  To  the  naked  eye  the  texture  of  tlie  gland  shows  nothing, 
abnormal ;  it  is  lobular  on  section  ;  in  one  or  two,  small  cysts 
appear,  and  in  the  largest  (taken  from  a  mild  case  of  cretinism) 
there  are  well-marked  hyperplastic  nodes.  Microscopically  all 
three  exhibit  a  condition  which  may  be  in  general  described  as  a 
deficiency  of  glandular  tissue  and  an  excess  of  connective-tissue. 
Two  of  them  are  less  altered  than  the  third,  which  is  markedly 
atrophic." 

Although  cretinism  is  most  often  seen  in  countries  where 
goitre  occurs  as  an  endemic  disease,  yet  isolated  cases  occur 
sometimes  in  districts  from  which  goitre  is  wholly  absent.     A 

*  No.  xxii.  1. 

f  A  similar  specimen  has  recently  been  added  to  the  museum  of  St.  Bartholo- 
mew's Hospital  (No.  2317c). 

X  No.  9.3.  §  Brit.  Med.  Jcmrn.,  Oct.  4,  1890. 


ATROPHY   AND    HYPERTROPHY.  27 

distinction  has  therefore  been  made  between  sporadic  and 
endemic  cretinism. 

It  has  been  asserted  bv  some  that  in  sporadic  cretinism  the 
thyroid  gland  was  absent,  while  in  endemic  cretinism  a  goitre 
might  or  might  not  be  present. 

Even  at  the  present  day,  there  appears  to  be  a  prevalent 
notion  that  there  is  some  essential  difference  between  them,  and 
while  some  observers  maintain  that  this  difference  is  to  be  fomid 
in  the  condition  of  the  thyroid  gland,  others  consider  that  it 
lies  in  the  presence  or  absence  of  certain  supra-clavicular  "  fatty 
tumours,""  which  have  been  described  in  connection  with  sporadic 
cretinism.* 

These  so-calledya^^?/  honours  of  cretinism  appear  to  have  been 
observed  much  more  often  during  life  than  after  death,  but, 
nevertheless,  there  are  records  of  post-mortem  examinations  of 
such  cases. 

During  life,  the  tumour  consists  of  a  lump  of  what  is 
apparently  fat,  developed  in  the  lower  part  of  the  posterior 
triangle  of  the  neck,  just  above  the  clavicle. 

Mr.  Curling,  who  appears  to  have  been  the  first  to  describe 
them,  says,  in  his  account  of  the  post-mortem  examination  of 
his  first  case  "  (the  swellings)  were  composed  of  fat,  and  occupied 
the  posterior  triangle  of  either  side  of  the  neck,  dipping  down- 
wards behind  the  clavicles  and  filling  the  axiilse.  .  .  .  They 
were  not  enveloped  in  a  capsule,  but  consisted  of  fat  of  a  loose 
lobular  nature."  In  the  account  of  the  second  case,  he  says 
that,  during  life,  "  on  the  sides  of  the  neck  beyond  the  sterno- 
cleido-mastoid  muscles,  were  two  soft  symmetrical  swellings, 
having  a  doughy  feel  and  incompressible."  Post  mortem,  the 
swellings  in  the  neck  were  found  to  consist  of  superficial  collec- 
tions of  fat  tissue,  without  any  investing  envelope,  and  loosely 
connected  to  the  surrounding  parts. 

In  Dr.  Fletcher  Beach's  case  of  sporadic  cretinism  in  a  child 
aged  three,  in  Avhich  the  "  usual  swellings  above  the  clavicle  were 
present  during  life,  at  the  autopsy  there  were  no  collections  of 
fat  or  other  swellino-s  at  either  side  of  the  neck.""  In  his  other 
case,  "  the  tumours  were  not   encapsuled,  and  hence  there  was 

*  See  observations  by  Dr.  Hilton  Fagge.  Pttf/t.  Sue.  TranA.,  vol.  xsv.  p. 
268. 


28  THE   THYROID   GLAND. 

some  difficulty  in  defining  their  limits.  .  .  .  There  was  a  layer 
of  fat  beneath  the  chin,  forming  a  double  chin." 

The  only  museum  specimen  of  the  fatty  tumours  of  cretinism 
that  I  have  been  able  to  find  is  that  of  Dr.  Hilton  Fagge  in 
Guy's  Hospital  ^Museum.*  The  tumours  were  described  by  him 
as  "  soft,  well-defined  masses  looking  like  fat,  but  distinctly 
differing  in  colour  from  those  in  their  neighbourhood."  Numer- 
ous processes  also  extended  in  yarious  directions  under  the 
clavicle,  down  into  the  axillae.  Sec. 

Such,  then,  are  the  "  supra-clavicular  fatty  tumours,"  Avhich 
are  said  to  be  so  characteristic  of  sporadic  cretinism  as  to  serve 
as  the  main  point  of  distinction  between  this  disease  and  endemic 
cretinism. 

I  do  not  consider  that  these  so-called  fatty  tumours  are  by 
any  means  characteristic  of  cretinism,  nor  do  I  think  that  there 
is  any  essential  difference  between  endemic  and  sporadic 
cretinism. 

The  post-mortem  examinations  above  mentioned  seem  to 
show  :  (i)  That  the  tumours  are  much  less  marked  after  death 
than  before ;  (ii)  That  the  tumours  are  not  well  defined,  but 
that  th(y^  consist  of  fat,  which  may  extend  from  the  axilla^  to 
the  chin,  in  fact  over  the  whole  region  of  the  neck  and  shoulders; 
(iii)  That  the  apparent  formation  of  a  definite  tumour 
depends  chiefly  upon  the  natural  anatomical  structure  of  the 
part.  The  absence  of  bone  or  large  muscles  in  the  supra- 
clavicular regions  allows  the  deep  seated  fat  to  protrude  more 
than  it  can  elsewhere.  Any  excessive  development  of  sub-fascial 
tissue,  whether  from  fatty  infiltration  or  from  the  presence  of 
oedema,  is  likely  to  cause  a  protuberance  in  the  posterior  triangles 
of  the  neck.  A  good  example  of  this  may  be  seen  in  P^ig.  14, 
where  a  "  fatty  tumour "  is  shown  which  is  exactly  similar 
to  that  of  cretinism.  The  patient  from  whom  the  photograph 
was  taken,  Avas  one  whom  I  saw  at  Leytonstone  with  Dr. 
Rotherham  Walker,  and  who  was  the  subject  of  well-marked 
myxoedema.  The  apparent  tumour  was  due  simply  to  the 
myxoedematous  affection  of  the  areolar  tissue  of  that  region. 

As  to  there  being  any  essential  difference  between  sporadic 
and   endemic  cretinism,  I   can  only  say  that  among  numerous 

*  Xo.  !).5. 


ATROPHY   AND    HYPERTROPHY. 


29 


cases  of  cretinism  which  have  come  under  mv  notice,  both  in 
England  and  in  Switzerland,  I  found  not  a  single  point  in  which 
the  members  of  one  class  differed  as  a  whole  from  those  of  the 
other. 

I  have  in  my  possession  two  photographs  taken  from  patients 


Fig.  is. — Groitrous  Cretinism,  a  female  ip.t.  2-5.  Slie  had  always 
lived  in  London.  The  g-oitre  had  been  noticed  only  within  the  last 
few  years.  Intelligence  considerably  greater  than  that  of  the  patient 
sho^'sTi  in  the  preceding  figure. 

who  had  lived  all  their  lives  in  this  country,  the  one  in  Wilt- 
shire, the  other  in  London.  Fig.  18  shows  the  latter  case.  Both 
may  fairly  be  considered  examples  of  sporadic  cretinism,  vet 
neither  has  a  supra-clavicular  tumour,  and  both  have  goitres. 
They  present  exactly  the  same  appearances  as  did  many  of  the 
cretins  that  I  saw  in  Berne. 


30  THE   THYROID   GLAND. 

Fig.  17  represents  another  case  of  sporadic  cretinism  from  a 
village  in  Wiltshire.  In  this  case  there  was  some  swelling  above 
the  clavicles.  There  was  no  obvious  goitre,  but  the  patient's 
mother  was  goitrous. 

Without  dividing  cretins  into  two  distinct  classes,  it  may  be 
said  that  some  are  much  more  swollen  than  others,  and  more 
like  adult  myxoedematous  patients.  Some  have  goitres,  while 
others  are  free  from  them.  Every  intermediate  grade  may, 
however,  be  met  with.  It  appears  to  be  a  fact  that  the  more 
swollen  a  cretin  is,  the  more  likely  he  is  to  be  without  a  goitre, 
and  vice  versd. 

It  is  said  to  be  a  popular  belief  among  the  Swiss  that  the 
presence  of  a  goitre  acts,  to  a  certain  extent,  as  a  protective 
against  cretinism. 

If  the  story  is  to  be  believed  that  was  told  to  me  by  the 
relatives  of  the  patient  shown  in  Fig.  18,  the  goitre  became 
larger  as  the  general  swelling  of  the  body  diminished.  I  have 
not,  however,  been  able  to  find  any  evidence  to  confirm  this 
statement,  which,  if  true,  is  one  of  considerable  interest. 

Complete  atrophy  of  the  thyroid,  then,  is  not  always  present 
in  cretinism,  whether  sporadic  or  endemic. 

There  is  much  reason,  however,  to  believe  that  in  all  cases 
there  is  some  disease  of  the  organ  which  impairs  its  function. 
This  disease  may  be  atrophy.  In  this  case,  the  swollen  condi- 
tion shown  in  Fig.  17  is  most  likely  to  be  present.  This  form 
of  cretinism,  is  very  closely  allied  to,  if  not  absolutely  identical 
with,  myxoedema.  On  the  other  hand,  the  disease  may  show 
itself  as  goitrous  enlargement  and  consequent  degeneration 
of  the  gland.  In  each  case,  the  gland  is  in  an  unhealthy 
condition. 

It  is  difficult,  nevertheless,  to  understand  why  some  goitrous 
persons  are  cretinous,  while  others  enjoy  good  health. 

The  treatment  of  cretinism  is  similar  to  that  of  myxoedema, 
and  consists  in  the  internal  administration  of  some  preparation 
of  thyroid  gland.  Removal  to  a  region  free  from  goitre  is  in 
most  cases  advisable.  If  treatment  be  commenced  sufficiently 
early,  and  carried  on  for  a  sufficient  length  of  time,  con- 
siderable benefit  may  be  expected,  both  as  regards  body  and 
mind. 


ATROPHY   AND    HYPERTROPHY.  31 

Hypertrophy. 

The  term  hypertrophy  is  frequently  applied,  loosely  and 
incorrectly,  to  many  forms  of  enlargement  which  should  be 
described  under  other  names,  such  as  parenchymatous  goitre, 
adenoma  of  the  thyroid,  etc.  True  hypertrophy  in  the  sense 
of  a  general  and  strictly  uniform  enlargement  of  all  parts 
and  constituents  of  the  gland  is  a  condition  but  rarely  seen. 
Indeed  it  is  doubtful  Avhether  the  term  hypertrophy  should  be 
used  at  all,  except  for  those  cases  in  which  one  part  of  the  gland 
u]  idergoes  enlargement  as  the  result  of  the  destruction,  by  disease 
or  injury,  of  the  other  parts.  In  such  cases  the  remaining  portion 
undergoes  compensatory  ox  physiological  hypertrophy  to  enable  it 
to  carry  on  the  functions  of  the  normal  gland. 

The  most  striking  example  of  the  kind  that  has  come  under 
my  own  notice  is  that  depicted  in  Figs.  19  and  20.  The  patient  was 
a  young  woman  from  whom  almost  the  whole  of  a  parenchymatous 
goitre  had  been  remoyed  by  operation  on  account  of  dyspnoea 
some  two  years  before  I  first  raw  her.  The  operation  was  sup- 
posed to  have  been  a  total  extirpation  and  was  actually  published 
as  such.*  Fortunately,  however,  a  small  piece  of  gland  was  left 
unnoticed  in  the  neck.  This  gradually  increased  in  size  until  it 
formed  a  tumour  as  large  as  a  hen's  egg,  that  is,  until  it  attained 
the  bulk  of  a  normal  thyroid.  With  the  hypertrophy  of  this 
piece  of  gland,  the  symptoms  of  commencing  cachexia  strumi- 
priva  caused  by  the  removal  of  the  organ  gradually  disappeared, 
until  eventually  the  patient  regained  perfect  health.  Further 
details  of  this  case  are  given  at  p.  325. f  This  is  true  physio- 
logical or  compensatory  hypertrophy  and  is  strictly  analogous  to 
the  hypertrophy  of  one  kidney  which  occurs  after  destruction  of 
its  fellow  by  injury  or  disease. 

Another  condition  closely  allied  to  hypertrophy  is  the  enlarge- 
ment which  occurs  in  the  malady  known  as  Graves's  disease, 
described  in  chap.  xii.  In  this  disease  it  is  the  epithelial 
elements  of  the  gland  that  are  especially  developed  and  form 
the  main  portion  of  the  swelling. 

A  simple  enlargement  of  the  gland  also  takes  place  under 
certain  conditions  which  may  be  mentioned  here.    It  is  doubtful 

*  Lancet,  1887,  vol.  ii.  p.  613.  .  f  See  also  Fig.  110. 


32  THE   THYROID    GLAND. 

however  whether  the  term  hypertrophy  ought  to  be  appHed  to 
these  conditions.  Possibly  in  some  of  these  cases  the  enlarge- 
ment is  temporary  and  is  due  merely  to  distension  of  the  gland 
with  increase  of  its  colloid  secretion,  rather  than  to  actual 
hypeitrophy. 

During  viendriiation,  the  normal  thyroid  is  said  to  become 


hi. 


Figs.  19  and  20.— From  a  girl,  cet.  17.  siiowiug-  re-eiilargement 
of  a  small  portion  of  a  goitre  (perhaps  an  accessory  I  thyroid  gland)  that 
had  been  left  behind  after  a  supposed  complete  removal.  The  opera- 
tion had  been  performed  at  the  Middlesex  Hospital  in  1884  on  account 
of  severe  dyspnoea.  A  few  weeks  after  the  operation  the  tumour  was 
as  large  as  a  hazel  mit,  after  two  years  it  had  attained  the  size  of  a 

enlarged  and  if  the  gland  happen  to  be  the  seat  of  pre-existing* 
enlargement,  the  increased  swelling  may  be  sufficient  to  cause 
severe  respiratory  symptoms.  Many  interesting  details  with 
regard  to  the  influence  of  menstruation  upon  the  thyroid  gland 
may  be  seen  in  a  paper  by  Dr.  E.  W.  Jenks.* 

T)\x\'\ng  pregnancy,  according  to  some  observers,  the  thyroid 

*  "  On  the  Relation  of  Goitre  to  Pregnancy  and  Derangement  of  the  Female 
Generative  Organs,"  by  E.  W.  Jenks,  Amer.  Jtmrn.  of  Obst.,  1881,  vol.  xiv.  p.  1. 


ATROPHY   AND    HYPERTROPHY. 


33 


gland  becomes  enlarged.  That  a  thyroid  already  goitrous  does 
usually  undergo  further  enlargement  at  this  time,  there  can,  I 
think,  be  no  doubt.  Over  and  over  again  have  goitrous  patients 
assured  me,  when  I  questioned  them  upon  the  point,  that  the 
goitre  always  became  larger  during  menstruation  and  pregnancy, 
and  the  onset  of  goitre  frequently  dates  from  a  pregnancy. 


w;iluut;  the  pliotogT.iplis  show  the  couuitiou  a  year  later  still,  wheu 
the  titmoitr  was  nearly  as  large  as  a  hen's  egg-.  There  was  great 
anaemia  and  weakness  (incipient  cachexia  strumipriva)  for  many  months 
after  the  operation,  but  as  the  tumour  increased  in  size  these  symptoms 
disappeared  and  eventually  the  patient  regained  perfect  health. 

But  whether  a  healthy  thyroid  gland  enlarges  during  preg- 
nancy is  not  quite  so  clear.  Probably  it  does  to  a  slight  extent. 
In  an  attempt  to  elucidate  this  point  I  examined  the  necks  of 
forty  pregnant  women.  In  most  of  them  the  pregnancy  had 
advanced  to  the  eighth  or  ninth  month.  In  two  only  could  I 
detect  any  thyroid  enlargement.  In  none  of  the  others  was 
there  any  perceptible  swelling  of  the  gland,  nor  could  the 
existence  be  ascertained  of  any  symptoms  which  could  be 
referred  to  such  an  enlarffement. 


34  THE   THYROID    GLAND. 

For  further  details  concerning  the  relation  of  pregnancy  to 
the  thyroid  gland,  reference  may  be  made  to  the  papers  of 
Jenks,  quoted  above,  and  of  Lawson  Tait.*  The  latter  quotes 
twelve  cases  from  his  own  practice  in  which  there  was  a  distinct 
connection  between  goitre  and  pregnancy.  In  many  cases 
(eleven  out  of  twelve  of  Lawson  Taifs)  a  distinct  tendency  to 
haemorrhage  is  found  to  co-exist  with  goitre.  I  have  noticed 
the  same  tendency  in  some  of  my  own  cases.  Dr.  Everley  Taylor 
of  Scarborouorh  tells  me  he  has  also  noticed  the  same  thing. 
Often  a  goitre  undergoes  increase  in  size  with  each  successive 
pregnancy,  regaining  partly  but  not  completely  its  original  size 
a  short  time  after  delivery. 

At  puberty  the  thyroid  frequently  undergoes  rapid  increase  in 
size.  A  large  number  of  endemic  goitres  are  found  to  have  first 
shown  themselves  at  this  period. 

It  will  be  seen,  in  a  subsequent  chapter,  how  much  more  often 
acute  swelling  of  the  gland  occurs  at  puberty  or  soon  after,  than 
at  any  other  period  of  life. 

It  is  said  that  during  sexual  excitement  considerable  increase 
in  the  size  of  the  thyroid  may  occur.  In  some  countries  there 
existed  and  I  believe  still  exists  a  curious  and  well-known  custom 
bearing  upon  this  point. f 

In  a  case  of  my  own,  that  of  a  young  man  with  a  large 
parenchymatous  goitre,  the  patient  assured  me  that  sexual 
excitement  was  always  followed  by  increase  in  the  size  of  his 
goitre  :  after  a  day  or  two  the  goitre  returned  to  its  usual  size. 
In  this  case  the  temporary  increase  in  size  was  usually  sufficient 
to  cause  distinct  dyspnoea. 

Before  leaving  the  subject  of  atrophy  and  hypertrophy  of  the 
thyroid  gland  attention  may  be  drawn  to  the  fact  that  the 
gland,  even  when  not  obviously  diseased,  varies  greatly,  not 
only  as  regards  its  size  and  weight  but  also  in  its  internal 
structure  as  seen  on  section.  Every  one  who  makes  systematic 
post-mortem  examinations  of  a  sufficiently  large  number  of 
thyroid  glands  will  notice  that  sometimes  the  gland  is  found 
to  be  firm  in  consistence  and   yellow  in   colour;  the   vesicles 

*  "  On  Enlargement  of  the  ThjToid  Body  in  Pregnancy,"  b}-  Lawson  Tait, 
Trans.  Edin.  Olst.  Soc.  vol.  iv.  p.  81-95. 

f  For  references  to  this  custom  see  "  Der  endemischer  Kropf,"  bj'  Dr.  Heinrich 
Bii'cher,  Basle,  1883,  pp.  6  and  7. 


ATROPHY   AXD    HYPERTROPHY.  35 

are  plainly  visible  to  the  naked  eye,  each  being  fully  distended 
with  its  thick  vellow  colloid  secretion ;  bv  pressure  this  can  be 
made  to  exude  slowly  from  the  cut  surface.  In  other  cases  the 
gland  is  dark  red,  tough  and  small ;  few  or  no  vesicles  are  visible 
to  the  naked  eve  and  there  is  apparentlv  almost  complete 
absence  of  colloid  substance.  ^'arious  stages  of  gradation 
between  these  two  conditions  may  be  seen. 

As  a  general  rule  it  may  be  stated  that  the  larger  thvroid 
with  much  secretion  is  most  often  found  in  the  bodies  of  persons 
who  have  died  of  some  wasting  disease  such  as  cancer  or 
phthisis. 

Conversely,  the  smaller  thyroid  with  little  secretion  is  usually 
seen  in  persons  who  are  stout,  with  much  subcutaneous  fat.  It 
is  perhaps  worthy  of  note  that  a  more  advanced  condition  of  the 
latter  state  of  thyroid  is  the  extreme  atrophy  seen  in  cases  of 
myxoedema.  Although  the  above  rules  do  not  by  any  means 
universally  hold  good,  yet  they  seem  to  point  to  some  inverse 
relation  between  the  amount  of  colloid  secretion  in  the  thyroid 
and  the  development  of  subcutaneous  fat.  It  mav  be  mentioned 
also,  as  a  fact  that  perhaps  bears  upon  this  question,  that  goitre 
is  rarely  seen  in  stout  people. 


CHAPTER   IV. 

GOITRE  AND  ITS  VARIETIES. 

Meaning  of  the  word  goitee — Parenchymatous — Cystic — Fibrous — 
Adenomatous  (foetal  and  cystic  adenomata)  —  Malignant  —  Ex- 
ophthalmic— Hemorrhagic — Colloid — "Vascular" — Endemic — Sporadic 
■ — Epidemic — Acute — Suffocating — Substernal — Intra-thoracic — Eetro- 
traeheal — Retro-oesophageal. 

The  term  goitre  is  a  corruption  of  the  Latin  "  guttur,"  the 
throat,  and  was  formerly  used  to  denote  any  swelling,  of  what- 
ever nature,  in  the  front  of  the  neck.  For  a  long  time,  however, 
the  term  has  been  restricted  to  a  swelling  of  one  particular  part, 
namely  the  thyroid  gland.  Many  authors  endeavour  to  restrict 
still  further  the  meaning  of  the  word,  and  to  limit  it  to  certain 
forms  of  swelling  of  this  organ.* 

The  simplest  and  at  the  same  time  the  commonest  form  of 
goitre  is  that  to  which  the  term  parenchymatous  f  is  applied. 
All  parts  of  the  gland  are  enlarged  equally,  or  nearly  so.  The 
goitre,  therefore,  is  always  bilateral,  and  preserves  the  shape  of 
the  normal  gland.  The  enlargement  is  caused  partly  by  accumu- 
lation of  colloid  material  within  the  vesicles,  and  partly  by  actual 
increase  in  the  solid  elements  of  the  gland  itself.  The  structure 
resembles  to  a  considerable  extent  that  of  the  normal  thyroid. 
It  forms  the  first  stage  in  the  formation  of  nearly  all  the  other 
varieties  of  goitre.     It  is  the  form  that  is  especially  common  in 

*  In  relation  to  the  changes  in  meaning  which  words  gradually  undergo,  it 
is  interesting  to  notice  that  one  of  the  two  words  commonly  employed  in 
Germany  to  signify  goitre,  is  "struma."  In  our  own  language,  when  applied  to 
swellings  in  the  neck,  this  word  has  refei'ence  to  swellings  of  the  lymphatic 
glands  rather  than  to  those  of  the  thyroid  gland.  The  use  of  the  term  goitre 
to  denote  enlargement  of  lymphatic  glands  has  now  become  entirely  obsolete. 

t  The  tei-m  "parenchymatous"  is  not  wholly  free  from  objection,  since  it  is 
not  merely  the  parenchyma  of  the  gland  that  is  affected  in  this  disease.  The 
term  is,  however,  a  convenient  one  and  may  therefore  be  retained. 


GOITRE   AND   ITS   VARIETIES.  37 

young  people.     It  is  rare  to  find  parenchymatous  goitre  begin- 
ning after  middle  life. 

Figs.  21,  22,  and  23  show  typical  cases  of  parenchymatous 
goitre  ;  in  these  cases  the  tumour  was  extirpated  on  account  of 
dyspnoea.  Figs.  24  and  25  show  a  somewhat  less  typical  case ; 
the  greater  enlargement  of  the  left  lobe  probably  indicates  the 


Fig.  21. — Parenchymatous  Goitre.  The  whole  gland  is  imlfovmly 
aud  greatly  eularged.  The  right  lobe  was  removed  by  operation  and 
is  now  in  the  Royal  Free  Hosp.  Mus.  No.  xxii.  10.  (See  Appendix, 
Case  75,  p.  348.) 

existence  of  one  or  more  cysts  or  adenomata  in  an  otherwise 
purely  parenchymatous  goitre.  Fig.  26  shows  the  appearance  of  a 
typical  parenchymatous  goitre  on  section  ;  the  vesicular  appear- 
ance of  the  gland  is  well  seen.  A  fresh  specimen  of  a  parenchy- 
matous goitre  has  a  soft,  spongy  feel,  and  sticky  colloid  matter 
readily  exudes  from  its  cut  surface. 

Cystic    goitre  is  the  term  applied  to  all  those  forms  of 
goitre  in  which  the  main  bulk  of  the  swelling  is  formed  by  one 


38 


THE   THYROID   GLAND. 


or  more  cysts  of  considerable  size.  Small  cysts  may  be  formed  by 
the  over-distension  of  single  vesicles  and  their  coalescence  with 
neighbouring  vesicles,  but  the  great  majority  of  thyroid  cysts 
aro   formed   in    an  entirely  different  way  by  the  liquefaction 


Ftgs.  22  and  23. — A  purely  ParencliyinatouS  Goitre  showing- 
sliglit   lobulation   and   thus   simulating'  a   ease   of   multiple 


and  gradual  breaking  down  of  solid  adenomatous  tumours.* 
Occasionally  a  thyroid  cyst  originates  in  an  extravasation  of 
blood  into  the  thyroid  tissues. 

Adenomatous  goitre  is  one  in  which  the  bulk  of  the 
enlargement  is  due  to  the  development  of  definite  encapsuled 
masses  of  atypical  thyroid  tissue  imbedded  in  the  gland. 
Sometimes  these  adenomata  occur  in  an  otherwise  healthy 
thyroid  gland,  but  in  the  great  majority  of  cases  an  adenoma  is 

*  For  illustrations  of  this  conversion  of  adenomata  into  cysts  see  Figs.  60,  61, 
and  62  on  pp.  153,  154. 


GOITRE   AND    ITS   VARIETIES. 


39 


associated  with  a  certain  amount  of  parenchymatous  enlarge- 
ment. Nearly  all  unilateral  and  asymmetrical  forms  of  goitre 
contain  either  adenomata  or  cysts. 

Fig.  27  shows  a  parenchymatous  goitre  that  has   been  cut 


adenomata.   •  (See  Appendix,  Casj  36,  p.  34i  aud  Koy.  Free 
Hosp.  Mus.  No.  xxii.  15.) 

transversely.  In  its  interior  are  seen  several  adenomatous 
masses  in  various  stages  of  formation. 

Fig.  28  shows  a  large  solid  adenoma  in  the  thyroid  gland  of 
an  elderly  woman. 

There  are  two*  principal  forms  of  adenoma,  the  foetal  and  the 
cystic. 

The  foetal  adenoma  is  met  with  chiefly  in  children  and  young 
adults,  and  is  composed,  as  the  name  implies,  of  tissue  resembling 

*  There  is  a  third  variety  of  adenoma  that  i^  fortunately  extremely  rare. 
This  is  the  so-called  maHf/>ia/i^  fuJrNoina,  which  will  be  discussed  more  fully  in 
chap.  xiii.  on  malignant  disease. 


40 


THE   THYROID   GLAND. 


liGs.  24  and  25. — A  JSihuriai  (■(>itn\  iii.iinly  parenchymatous- 
situiitei  low  dowu  aud  eventually  causiug-  very  severe  dyspua'a. 
(From  an  outpatient  seen  at  St.  Bartliolomew's  Hospital.) 


GOITRE   AND   ITS   VARIETIES.  41 

that  of  the  normal  foetal  thyroid.  To  the  naked  eye  it  presents 
a  solid  homogeneous  appearance.  Microscopically  it  is  com- 
posed chiefly  of  masses  of  epithelial  cells,  representing  undevel- 


FiG.  26.— Section  of  a  Parenchymatous  Goitre  removed  by  opei-a- 
tiou  on  account  of  dyspnoea.  Thj  dark  parts  show  colloid  material 
distending-  the  thyroid  vesicUs.  From  a  boy  aged  15  (Case  22*). 
(See  Koy.  Free  Hosp.  Miis.  No.  xxii.  11.)     (Nat.  size.) 

oped  thyroid  vesicles.  Fig.  29  shows  a  normal  thyroid  gland 
from  a  six  months  foetus,  and  is  introduced  here  for  comparison 
with  Fig.  30,  which  shows  an  ordinary  foetal  adenoma  removed 
by  operation  from  a  goitrous  patient  aged  twenty-five.     Foetal 

*  Published  in  Brit.  Med.  Juurn.,  July  7.  1900. 


42 


THE   THYROID   GLAND. 


adenomata  seldom  attain  a  large  size.  The  largest  that  I  have 
iiivself  ever  had  to  remove  was  not  larger  than  an  orange.  They 
are  of  importance  chiefly  on  account  of  their  vascularity.    Opei'a- 


Fjc.  27. — Section  of  Goitre  removed  by  operation,  from  a  woman  aged  39, 
on  account  of  severe  dyspnoea.  Numerous  adenomata  of  various 
sizes  are  seen.  The  white  portions  show  coagiilated  colloid.  (See 
Appendix,  Case  30,  p.  344  and  Eoyal  Free  Hosp.  3Ius.  No.  xxii.  23.) 
( Slightly  enlarged,  ^.) 

tions  for  their  removal  are  apt  to  be  attended  by  smart  haemor- 
rhage. 

The  cystic  adenoma   is  by  far  the  most  common  form   of 
adenoma.     It  differs  from  the  preceding  in  containing  numerous 


GOITRE   AND    ITS   VARIETIES. 


43 


cavities  visible  to  the  naked  eye.  The  microscopic  structure 
(see  Fig.  31)  resembles  to  a  certain  extent  that  of  the  normal 
th}Toid,  but  the  vesicles  are  usually  more  irregular.,  and  show 
a   tendencv  to   run  one  into   another,   owing  to   the   breaknig 


?>.^\ 


.    ^^ 


:»-a 


■^^:.,^^_ 


Fig.  28.— KigliT  LoljL-  of  a  Thyroid  Glaud  sliowiuo-  at  the   lower  part   a 
lnvge   soUd  Adenoma.     (Koyal   Free   Hosp.   Mas.   Xo.  xxiL    31.) 

( Enlarg-ed  ±.) 

down  of  the  intervening  tissue.  The  connective-tissue  between 
the  vesicles  is  usually  more  abundant  than  in  the  normal  thyroid. 
Cysts  of  various  sizes  are  seen  in  the  tumour.  They  contain 
colloid  matter  and  frequently  blood. 

Fibrous   Goitre. — Occasionally  a  general  increase  in  the 


44  THE   THYROID   GLAND. 

amount  of  connective^tissue  in  the  gland  forms  the  bulk  of  the 
goitre.  To  such  the  name  of  fibrous  goitre  may  be  applied. 
The  purely  fibrous  goitre  is,  however,  a  very  much  less  common 
form  than  is  generally  believed. 

All  the  above-mentioned  varieties  may  run  one  into  another, 
so  that  we  frequently  meet  with  mixed  forms.  Thus  the  paren- 
chymatous goitre  almost  always  contains  small  cysts,  and 
frequently  one  or  more  large  ones.  So  do  many  adenomata. 
Both    parenchymatous    and    cystic    goitres    frequently    contain 


Fig.  29. — Tbyroid  i  Gland  l)-om  ;i  FcetuS  of  Six  Mouths.  Tlie  gland 
is  arranged  iu  lobnles  and  is  almost  solid.  The  rudimentary  vesicles 
contain  very  little  colloid.     (  x   90  di:im.) 

much  fibrous  tissue,  and  adenomatous  nodules  may  be  found  in 
association  with  any  of  the  preceding  varieties.  Fig.  32  shows 
an  old  goitre  with  several  adenomata  and  much  fibrosis. 

There  are  two  other  important  varieties  of  goitre  that  stand 
somewhat  apart  from  all  the  preceding.  These  are  malignant 
goitre,  in  which  the  tumour  consists  wholly  or  in  part  of 
malignant  disease  (carcinoma  or  sarcoma),  and  exophthalmic 
goitre  or  the  goitre  of  Graves's  disease. 

Both  these  forms  of  goitre  differ  widely,  both  structurally  and 
clinically,  from  the  preceding  varieties. 

There  are  several  other  minor  varieties  which  have  received 


GOITRE   AND   ITS   VARIETIES. 


45 


Fig.  30. — A  Pcetal  Adenoma  fi-om  a.  Udy  agei  2.5.  it  consists  cliiufly 
of  solid  masses  of  cells,  with  immcrous  vascular  spaces  (white).  Thei'e 
are  hardly  auy  vesicles  and  uo  colloid,     (x  90  diam.)     (Case  25.) 


Fig.  31. — Portiou  of  a  Cystie  Adenoma  from  a  woman  aged  21. 
Numerous  small  cysts  of  various  sizes  and  full  of  colloid  are  seen  lying' 
in  a  matrix  of  coniiestive  and  glaudular  tissues.  (Appendix,  C:ise  99, 
p.  350.)     (  X   90  di.im.) 


46 


THE   THYROID   GLAND. 


separate  names.     H£emorrhagic  goitre  is  a  term  used  to 
signify  a  condition  in  which  haemorrhage  takes   place  into  a 


V 


,  .;,  »   ^«?■^5" 


Fig.  32.— Section  of  part  of  a  Goitre  removed  by  operation  from  a  woman 
aged  43,  on  account  of  severe  dyspnoea.  Several  Adenomata  are 
seen  imbedded  in  a  Parenchymatous  Goitre  which  has  under- 
gone much  fibroid  idegeneration.  (See  Appendix,  Case  34,  p.  3i4,  and 
Koyal  Free  Hosp.  Mus.  Xo.  xxii.  25.)     (Slightly  enlarged.) 


goitre,  generally  a  cystic  one,  or  in  which  an  innocent  goitre 
causes  ulceration  of  the  skin  over  it  and  bleeds  externally.  {See 
Fig.  33.) 

Colloid  goitre  is  a  term  applied  by  some  authors  to  paren- 


GOITRE   AND   ITS   VARIETIES. 


47 


chymatous  goitres  in   which  the  colloid   material  is  unusually 
abundant  and  obvious.* 

The  term  vascular  goitre  is  one  that  is  frequently  heard, 
and  is  often  applied  to  the  goitre  of  Graves's  disease.    The  term 


Fig.  33. — "  Haemorrhagie  Cyst."  The  right  lobe  of  the  thjroid  is 
occupied  by  a  large  cyst,  Tvhich,  after  removal,  was  found  to  be  filled 
with  uearly  pure  blood.  Several  severe  haemorrhages  had  taken  place 
from  the  ulcerated  opening  on  the  surface.  (From  a  woman,  aged  60, 
seen  at  the  Kensington  Infirmary  with  Mr.  H.  P.  Potter,  under  whose 
care  she  was.  The  tumour  is  noT\'  in  tlie  Museum  of  the  Royal  College 
of  Surgeons,  Xo.  2905a.) 


is,  however,  a  bad  one,  and  should,  in  my  opinion,  not  be 
employed.  If  it  be  intended  to  signify  a  goitre  composed 
mainly  of  blood-vessels,  then  it  is  a  name  for  what  probably  does 

*  A  good  example  of  such  a  goitre  may  be  seen  in  the  Eoyal  College  of 
Sm-geons'  Museum,  No.  2908D, 


48  THE   THYROID   GLAND. 

not  exist,  for  there  is  no  evidence  of  the  existence  of  any  such 
o-oitre.  If  it  be  used  for  the  goitre  of  Graves's  disease,  it  conveys 
a  false  impression  that  the  enlargement  that  is  present  in  that 
form  of  goitre  is  mainly  due  to  unusual  vascularity  in  the 
gland.     This  is  an  erroneous  but  widespread  belief. 

Amyloid,  syphilitic,  and  tuberculous  goitre  are  all 
of  them  extremely  rare  ;  the  names  explain  themselves.  It  is  to 
my  mind  doubtful  whether  the  cases  described  as  amyloid  disease 
of  the  thyroid  are  really  of  that  nature.* 

The  terms  endemic  and  sporadic  goitre  refer,  not  to 
pathological  varieties  of  the  disease  but  to  its  distribution  and 
causation.  The  same  may  be  said  of  epidemic  goitre,  a 
term  that  is  used  for  goitre  when  it  attacks  a  number  of  people 
in  the  same  place  and  at  or  about  the  same  time. 

Acute  goitre  is  a  term  used  to  denote  a  goitre  that  develops 
rapidly,  es})ecially  in  young  subjects. 

Suffocating  goitre  is  naturally  any  goitre  that  produces 
much  dyspnoea. 

Substernal,  intra-thoracic,  retro -tracheal,  and 
retro -oesophageal  goitre  are  terms  that  explain  them- 
selves. 

*  See  remarks  on  pp.  34,  35.  concerning-  the  yellow  waxy  looking  thyroid  found 
in  emaciated  persons. 


CHAPTER   V. 

ENDEMIC  GOITRE— CAUSATION  AND  DISTRIBUTION. 

Alleged  causes — Climate — Physical  configuration  of  soil — "Want  of 
air  and  sunshine  "  theory — Erroneous  nature  of — Eelation  to  geology — 
Geological  and  geographical  distribution  in  England — Eelation  to 
calcareous  rocks  and  waters  derived  from  them — Lime — ilagnesia — 
Iron — Organic  impurities — Epidemic  goitre — Goitre  wells — Artificial 
production  of  goitre — Goitre  in  lower  animals — Habits  of  life,  exertion, 
strain,  etc. — Heredity — Conclusions. 

Thehe  can  be  but  little  doubt  that,  in  the  great  majority  of 
cases,  goitre  is  to  be  regarded  as  an  endemic  disease.  It  is  well 
known  that  in  some  parts  of  the  world,  the  endemicity  is  present 
in  a  high  degree.  In  other  parts  where  the  cause  or  causes 
are  less  powerful,  the  disease  is  less  common  and  the  endemi- 
city is  not  so  obvious.  It  is  exceedingly  difficult  to  know 
where  to  draw  the  line  between  endemic  and  sporadic  goitre. 

Probably  in  this  country,  most  goitres  mav  fairlv  be  considered 
to  belong  to  the  endemic  class,  but  the  endemicity  is  so  widely 
spread  oyer  the  country  while  at  the  same  time  it  is  so  slight, 
that  it  easily  escapes  notice,  and  cases  of  goitre  are  often 
considered  to  be  sporadic  which  should  more  coiTectly  be  classed 
as  endemic. 

One  kind  of  goitre,  however,  the  exophthalmic  variety,  stands 
quite  apart  from  all  others,  both  structurally  and  in  its  geogi'aphi- 
cal  distribution. 

This  form  will  be  dealt  with  subsequently  in  chap.  xii. 

With  the  exception  of  exophthalmic  goitre,  there  is  no 
structural  difference  between  sporadic  and  endemic  goitre. 

But  although  goitre,  in  most  cases,  is  to  be  regarded  as  an 
endemic  disease,  caused  bv  a  definite  poison,  whatever  that 
poison  may  be,  it  is  impossible  to  assert  that  all  cases  of  goitre 
originate  from  the  same  cause.     To  cite  an  analogous  example  : 

D 


50  THE   THYROID   GLAND. 

there  are  many  malarious  districts  in  which  a  considerable 
number  of  the  inhabitants  suffer  from  enlargement  of  the  spleen 
caused  by  the  malarial  poison.  But  enlaro-ement  of  the  spleen 
may  be  due  to  other  causes  than  malaria ;  and  just  as  we  do  not 
consider  every  case  of  enlargement  of  the  spleen  to  be  malarious 
in  its  origin,  so  we  need  not  consider  every  case  of  goitre,  even 
when  it  is  found  in  a  markedly  goitrous  district,  to  be  due  to  the 
same  poison  that  usually  produces  the  disease. 

The  number  of  theories  that  have  been  advanced  to  account 
for  the  causation  of  endemic  goitre  is  very  great.  St.  Lager  * 
in  his  classical  work  upon  the  subject  mentions  more  than  forty 
and  occupies  no  less  than  four  pages  of  his  book  in  simply 
enumerating  these  different  theories  and  the  names  of  the 
authors  who  have  supported  them. 

In  endeavouring  to  ascertain  the  relative  frequency  of  goitre 
in  different  parts  of  England,  one  is  met  by  this  great  difficulty 
that  there  exists  no  source  from  which  reliable  statistical  infor- 
mation can  be  obtained.  In  France,  Germany,  Switzerland  and 
many  other  foreign  countries,  there  does  exist  such  a  source, 
namely  the  official  returns  of  the  number  of  young  men  who 
have  been  exempted  from  military  service  on  account  of  goitre. 

From  the  statistics  thus  obtained,  maps  have  been  constructed 
which  show  fairly  accurately  the  distribution  of  goitre  in  these 
countries.  Excellent  maps  of  this  kind  have  been  published, 
for  example,  in  Switzerland  by  Bircher  and  in  France  by  Baillarger 
and  Nivet.  In  this  country,  however,  there  exists  no  such  means 
of  obtaining  information. 

The  alleged  causes  of  endemic  goitre  may  be  conveniently 
discussed  under  the  following  heads  : 

(1)  Climate  and  other  atmospheric  conditions. 

(2)  Physical  configuration  of  the  soil. 

(3)  Geological  structure  of  the  soil,  and  its  influence  upon 
drinking  water. 

(4)  Habits  of  life,  exertion,  strain,  etc. 

(5)  Heredity. 

(1)  Climate. — That  climate  has  little  or  no  influence  upon  the 
production  of  goitre  is  shown   by  many  facts.     Although  the 

*  "Etudes  siir  les  Causes  du  Cretinisme  et  du  Goitre  Endemique,"  J.  St. 
Lager,  Paris,  1867.  ■ 


ENDEMIC   GOITRE.  51 

disease  appears  to  be,  on  the  whole,  most  prevalent  in  temperate 
zones,  yet  it  is  by  no  means  limited  to  them.  It  has  been  found 
in  extremely  cold  regions  such  as  the  north  of  Siberia  and  in 
the  Hudson's  Bay  Territory  of  North  America,  and  also  in 
the  tropics.  My  friend  Dr.  Sidney  Davies,  late  of  Cairo, 
informs  me  that  he  has  seen  it  among  the  Egyptians.  Accord- 
ing to  other  observers,  it  occurs  also  in  the  Soudan  and  in  the 
Andes  near  the  equator.  It  is  also  well  known  to  be  common 
in  some  of  the  hottest  parts  of  India.  That  heat  and  cold  have 
no  share  in  the  production  of  the  disease,  there  can  thus  be  but 
little  doubt. 

Some  authors  have  endeavoured  to  show  that  the  prevalence 
•of  goitre  is  dependent  upon  the  amount  of  rainfall,  but  I  have 
failed  to  confirm  this  statement. 

The  map  published  in  the  Sixth  Report  of  the  Rivers  Pollution 
Commission  shows  that  in  England  the  annual  rainfall  is 
greatest  in  the  centre  of  Devonshire  and  in  the  Lake  district, 
being  over  fifty  inches  in  each  of  these  localities.  Now  the 
neighbourhood  to  the  south-east  of  Dartmoor  is  one  from  which 
I  know  goitre  to  be  almost  entirely  absent.  Similarly,  in  the 
neighbourhood  of  Windermere,  goitre  is,  as  I  am  informed  by  my 
friend  Dr.  John  Mason,  distinctly  rare.  On  the  other  hand  I  have 
found  goitre  to  be  common  in  parts  of  Buckinghamshire  and 
Bedfordshire,  where  the  annual  rainfall  is  less  than  twenty-five 
inches.  Probably  the  real  reason  why  goitre  has  been  associated 
with  excessive  rainfall  is  because  it  is  chiefly  in  mountainous 
regions  that  goitre  is  most  common,  and  it  is  also  on  mountains 
that  we  expect  to  find  the  greatest  amount  of  rain. 

Rarity  of  the  atmosphere  has  been  assigned  as  a  cause  of 
goitre,  chiefly  also  on  account  of  the  known  prevalence  of  the 
disease  in  certain  mountainous  districts  such  as  the  Alps, 
Pyrenees  and  Himalayas.  But  here  again,  closer  examination 
shows  that  it  is  not  to  the  rarity  of  the  atmosphere  that  goitre 
is  due.  In  Switzerland  it  has  been  shown  that  in  manv  of  the 
highest  inhabited  parts  of  the  Alps  goitre  is  absent.  In  this 
country  I  have  not  been  able  to  find  that  the  disease  bears  any 
definite  relation  to  the  altitude  of  the  district  in  which  it  occurs. 
It  has  been  stated  by  some  that  goitre  is  unknown  upon  the  sea 
coast,  but  I  have  myself  observed  cases  among  people  who  lived 


52  THE   THYROID    GLAND. 

and  had  always  lived  close  to  the  shores  of  the  Burry  estuary  in 
Glamorganshire.  Some  of  these  goitrous  people  lived  but  a  few 
feet  above  the  sea-level. 

(2)  Physical  Configuration  of  the  Soil. — Allusion  has  already 
been  made  to  the  prevalence  of  goitre  upon  most  of  the  great 
mountain  chains  of  the  world.  In  F)'ance,  especially,  is  this 
connection  apparently  striking.  Nivet,  in  his  excellent  mono- 
graph upon  goiti'e,*  gives  for  each  department  of  France,  the 
number  of  recruits  rejected  from  military  service  on  account  of 
this  disease.  The  four  departments  for  which  the  figures  are 
highest,  are  Hautes  Alpes,  Hautes  Pyrenees,  Aisne  and  Vosges 
(9-28,  3-33,  2-84  and  2-77,  per  thousand,  respectively).  It  is 
worthy  of  notice  that  three  out  of  four  of  these  departments 
are  occupied,  as  the  very  names  imply,  by  well-known  mountain 
chains. 

In  our  own  country,  too,  there  are  many  hilly  parts  in  which 
goitre  is  common.  The  Pennine  range  in  Derbyshire  and 
other  countries  in  the  centre  and  north  of  England  is  well 
known  to  be  a  great  seat  of  goitre.  Less  known,  but  never- 
theless well  marked,  is  the  prevalence  of  the  disease  among 
the  Cotswold  Hills  of  Gloucestershire  and  neighbouring 
countries. 

But  on  the  other  hand,  there  are  many  mountainous  countries 
in  which  goitre  is  very  rare  or  altogether  absent. 

One  of  the  best  examples  that  can  be  adduced  of  a  mountainous 
country  almost  entirely  free  from  goitre,  is  Norway. 

In  the  highlands  of  Scotland,  too,  goitre  appears  to  be  almost 
unknown. 

It  is  not,  then,  the  mountainous  nature  of  a  country  alone 
that  causes  goitre.  If  one  of  the  mountainous  districts  in  which 
goitre  is  prevalent  be  examined  more  closely,  it  will  often  be 
found  that  it  is  only  in  certain  parts  of  the  mountains  that  the 
disease  occurs.  Thus  in  Switzerland,  the  higher  parts  of  the 
Alps  are  much  less  affected  than  the  lower,  and,  speaking 
generally,  it  may  be  said  that  goitre  is  more  often  found  at  the 
foot  of  a  hill  or  mountain  than  near  the  summit. 

Bircher  of  Aarau  has  constructed,  from  the  military  statistics 
of  Switzerland,  an  excellent  map  showing  the  exact  distribution 

*  Nivet  "Traite  du  goitre,"  Paris,  1880. 


ENDEMIC   GOITRE.  53 

of  goitre  in  everv  part  of  that  country.  It  may  be  seen  from 
this  map  that  in  some  parts  of  the  country,  especially  in  the 
cantons  of  Berne  and  Fribourg,  the  percentage  of  goitre  is 
eighty  or  eyen  ninety.  Now,  the  highest  gi'ound  in  Switzerland 
is  that  occupied  by  the  main  chain  of  the  Alps  in  the  southern 
and  south-eastern  part  of  the  country.  But  the  district  in 
which  goitre  is  most  preyalent  is  that  \vhich  lies  to  the  north 
of  the  Alps,  stretching  from  the  canton  Fribourg  in  a  north- 
easterly direction  towards  Lake  Constance. 

It  has  been  asserted  that  goitre  is  not  so  preyalent  on  the 
most  exposed  parts  of  mountains,  but  occurs  rather  in  the 
valleys  upon  the  slopes  of  the  mountains,  and  this  is  to  a 
certain  extent  true.  Perhaps,  nowhere  in  the  world,  is  the 
disease  so  common  as  it  is  in  some  of  the  deep  yalleys  of  North 
Italy,  on  the  southern  side  of  the  Alps,  in  that  of  Aosta,  for 
example.  In  Sayoy,  at  the  western  end  of  the  Alps,  a  similar 
distribution  may  be  noticed.  The  Rhone  yalley,  especially 
between  Brieg  and  Martigny,  is  a  well-known  example.  In 
our  own  country  a  similar  prevalence  of  goitre  in  valleys  may 
be  noticed.  Among  the  Cotswolds,  the  villages  situated  in 
valleys  appear  to  be  chiefly  affected. 

This  marked  prevalence  of  goitre  in  valleys,  and  especially 
in  the  valleys  of  mountainous  regions,  has  led  to  a  widely 
accepted,  but  an  entirely  erroneous  theory  of  the  cause  of  goitre, 
namely,  that  it  is  due  to  zcant  of  air  and  sunshine. 

At  first  sight,  the  theory  seems  plausible  enough.  No  one 
Avho  has  visited  the  valleys  in  Switzerland,  in  which  goitre  is  so 
prevalent,  can  have  failed  to  notice  that  many  of  them  are  deep, 
narrow,  and  gloomy. 

But  if  the  depth,  the  naiTowness,  and  the  gloominess,  of 
valleys  and  the  consequent  lack  of  air  and  sunshine  in  them, 
were  the  real  cause  of  the  goitre,  then  Ave  ought  to  find  the 
disease  prevalent  in  all  similar  vallevs  in  other  parts  of  the 
world.  Norway  may  be  cited  as  a  country  in  which  such  valleys 
abound.  Yet  evidence  is  quite  wanting  to  show  that  goitre  is 
at  all  common  there.  In  the  course  of  four  visits  to  the  western 
parts  of  Norway,  I  failed  to  see  a  single  case  of  goitre. 

Again,  if  want  of  air  and  sunshine  w^re  the  cause  of  goitre, 
the   disease  ought  to  be   connnon  among  printers   and   others 


oi  THE   THYROID   GLAND. 

whose  occupations  often  compel  them  to  work  at  night  in 
crowded  and  ill-ventilated  work-rooms. 

^Miners,  too,  can  hardly  be  supposed  to  get  their  full  share  of 
sunshine  and  of  good  air.  But  inquiry  among  them  has  not 
shown  that  they  are  particularly  liable  to  the  disease.* 

The  horses,  too,  that  work  for  years  in  mines,  and  never  see  a 
rav  of  sunshine,  are  not  especially  liable  to  the  disease.  Yet 
horses,  as  well  as  other  animals,  are,  like  man,  subject  to  goitre, 
in  districts  where  it  is  prevalent. 

Some  of  our  text-books  state  that  goitre  is  especially  common 
in  the  overcrowded  and  poorer  parts  of  our  great  cities,  but  the 
statement  does  not  rest  upon  any  solid  foundation  of  fact. 
Indeed,  it  may  confidently  be  asserted  that  in  the  east  end  of 
London,  as  well  as  in  the  poorer  parts  of  most  of  the  largest 
English  towns,  goitre  is  not  nearly  so  common  as  it  is  in  many 
country  villages  situated  far  more  favourably  as  regards  pure 
air  and  sunshine. 

In  the  village  of  Chacombe,  in  Northamptonshire,  I  found 
numerous  cases  of  o-oitre.  This  villao-e  is  situated  in  a  more  or 
less  sheltered  hollow  among  the  hills,  and  it  might  be  supposed 
that  its  position  alone  was  the  cause  of  the  goitre.  But  a  mile 
away  is  a  farmhouse  situated  upon  the  very  top  of  the  hill,  in 
an  exposed  and  open  situation ;  in  this  house  several  members 
of  one  family  have  suffered  from  goitre  ;  one  of  them  actually 
died  from  suffocation  caused  by  the  disease. 

A  similar  example  is  afforded  by  the  village  of  Oberbalm  in 
the  canton  of  Berne.  Here  the  percentage  of  goitre  among 
the  recruits  is  twenty-three.  The  village  is  situated  near  the 
top  of  a  hill ;  on  the  very  summit  is  a  farmhouse ;  among  the 
inhabitants  who  had  always  lived  in  it  during  the  whole  of  their 
lives,  I  found  well-marked  goitre.  So  exposed  is  the  situation 
of  this  farm,  that  from  it  I  could  see,  on  the  one  side,  the 
glaciers  of  the  Bernese  Oberland,  forty  miles  away,  while  in  the 
opposite  direction  was  visible  the  equally  distant  range  of  the 
Jura  in  France. 

A^^ere    it  necessary  to  do    so,  many  more    similar  examples 

*  It  should  be  remembered  that  some  mines  naturalh-  exist  in  goitrous 
districts,  as  in  the  carboniferous  limestone  regions  of  Derbyshire  and  Yorkshire 
and  that  in  these  regions  ■\ve  find  goitre  just  as  common  among  miners  as 
among  other  inhabitants  of  the  same  districts,  but  not  more  so. 


ENDEMIC   GOITRE.  55 

might  be  cited,  pointing  towards  the  fact  that  endemic  goitre 
may  be  found  in  elevated  and  exposed  situations,  where  good 
air  and  sunshine  are  abundant. 

It  seems  clear  that,  although  certain  valleys  contain  a  great 
deal  of  goitre,  yet  the  disease  is  quite  absent  from  others  which 
are  equally  deep,  narrow,  and  gloomy,  equally  devoid  of  pure 
air  and  sunshine. 

(3)  Geological  Structure  of  the  Soil  in  relation  to  goitre. — 
The  true  explanation  of  the  association  of  goitre  with  hills  and 
valleys  is  to  be  found,  I  believe,  not  in  the  mere  external  con- 
figuration of  the  ground  but  in  its  geological  structure  and  the 
influence  which  this  has  upon  the  drinking  water  of  the  district. 

Water  which  has  percolated  through  thick  masses  of  pervious 
and  more  or  less  soluble  rock  contains,  cateris  paribus,  more 
mineral  constituents  than  water  which  has  not  done  so.  Hence 
water  issuing  at  the  foot  of  a  hill  composed  of  such  rock  is 
likely  to  contain  a  considerable  quantity  of  mineral  matter. 
The  nature  and  quantity  of  the  minerals  will  naturally  depend 
upon  the  nature  and  solubility  of  the  constituents  of  the 
rock. 

The  close  connection  between  goitre  and  limestone  was  pointed 
out  long  ago.  MacClelland  especially  has  brought  forw^ard  striking 
facts  to  illustrate  this  point.* 

Now  it  is  in  limestone  and  sandstone  districts  especially  that 
we  meet  with  deep  and  narrow  valleys.  At  the  foot  of  a  great 
mountain  chain  we  generally  find  extensive  deposits  of  these 
rocks,  the  upper  parts  of  the  mountains  being  often  composed 
of  granite,  gneiss,  and  other  crystalline  rocks.  Such  is  the 
structure  of  the  Alps.  The  mountain  streams  descending 
rapidly  from  the  higher  levels  will  generally  cut  deep  and 
narrow  valleys  in  the  limestones  and  sandstones  which  they 
meet,  and  thus  are  formed  the  typical  valleys  in  which  goitre  is 
most  abundant.  When  the  valleys  occur  among  rocks  which  do 
not  readily  allow  of  percolation  and  solution  such  as  those  in  the 
West  of  Norway  there  we  find  that  goitre  is  not  common  in 
them. 

A  vast  amount  of  work  has  been  done  by  those  who  have 
laboured   to    trace   a    causal    connection    between    goitre    and 

*  "  Observations  on  Goitre,"  2>«w.s".  M.  and  Pliyy.  Sor.  Calcutta,  1834,  vii. 


56  THE   THYROID   GLAND. 

geology.  That  there  is  a  more  or  less  direct  connection  cannot, 
I  think,  be  denied.  If  a  comparison  be  made  of  two  maps  of 
Switzerland,  one  geological,  the  other  showing  the  distribution 
of  goitre,  it  cannot  fail  to  be  observed  that  the  area  over  which 
goitre  is  most  common  corresponds  roughly  with  the  region  of 
that  great  deposit  of  sandstones,  marls  and  limestones  known  as 
the  molasse.  Further,  it  is  especially  upon  the  marine  molasse 
that  the  disease  is  seen  to  be  most  plentiful,  although  there 
are  also  other  deposits  upon  which  it  occurs.  It  is  scarcely 
possible  to  resist  the  conclusion  that  in  Switzei'land  at  least, 
there  must  be  an  intimate  causal  connection  between  goitre  and 
the  geological  nature  of  the  soil  upon  which  it  is  found,  and 
that  the  marine  molasse  is  one  at  least  of  the  geological  formations 
that  give  rise  to  goitre. 

The  conclusions  arrived  at  by  Bircher  who  has  studied  the 
subject  very  carefully  in  Switzerland  are  as  follows : 

(1 )  Goitre  occm's  only  upon  marine  deposits  and  especially 
upon  the  marine  sediments  of  the  palaeozoic,  triassic  and  tertiary 
periods. 

(2)  Free  from  goitre  are  eruptive  rocks,  the  crystalline  rocks 
of  the  Archaean  group,  the  sediments  of  the  Jurassic,  cretaceous 
and  post-tertiary  seas  as  well  as  all  fresh  water  deposits. 

With  these  conclusions  I  am  on  the  whole  disposed  to  agree, 
although  as  far  as  England  is  concerned,  it  is  not  correct  to 
assert  that  Jurassic  and  cretaceous  rocks  are  wholly  free  from 
goitre.  Endemic  goitre  does  undoubtedly  occur  upon  both 
these  formations,  although  somewhat  sparselv,  especiallv  as  far 
as  the  chalk  is  concerned. 

It  may  be  well  to  point  out  that  in  investigating  the  relation 
of  geology  to  goitre,  care  should  be  taken  to  bear  the  following 
facts  in  mind. 

Geological  formations  are  classified  according  to  the  period  at 
which  they  were  formed  and  not  necessarily  accordingly  to  their 
chemical  composition  or  mineralogical  structure.  Hence  two 
rocks  totally  different  in  composition  may  bear  the  same 
geological  name.  It  would  obviously  be  wrong  to  draw  conclu- 
sions from  them  respecting  goitre,  as  if  they  were  the  same. 

On  the  other  hand  sometimes  even  large  formations  such  as 
the  chalk  are   tolerably  uniform  in  composition  and  structure 


ENDEMIC   GOITRE.  57 

over  wide  areas,  and  these  are  particularly  well  suited  for 
purposes  of  investigation. 

Again,  the  occurrence  or  not  of  goitre  upon  a  particular 
formation  depends  not  merely  upon  the  formation  but  upon  the 
water  supplying  the  people  who  live  upon  it.  Thus  a  village 
mav  be  seated  upon  soil  not  usually  the  seat  of  goitre  and  may 
yet  be  affected  with  the  disease.  The  converse  is  equally  true ; 
a  village  or  town  situated  in  a  goitrous  district  upon  rocks 
usuallv  associated  with  the  disease  mav  remain  exempt  if  it 
derives  its  water  supply  from  some  distant  source,  from  rocks 
not  associated  with  the  disease. 

Again,  the  drinking  water  supplying  any  particular  village  or 
district  may  be  derived  from  some  verv  deep  seated  source  quite 
unconnected  with  the  rocks  at  the  surface.  In  this  case,  if  the 
water  be  such  as  will  produce  goitre,  it  matters  not  in  the  least 
whether  the  surface  rocks  are  or  are  not  those  on  which  the 
disease  is  usually  found.  Great  care  must  therefore  be  taken 
lest  erroneous  conclusions  be  drawn.* 

The  relation  between  geology  and  water  supply  is  an  exceed- 
ingly complex  subject  and  is  especiallv  complicated  in  our  own 
country  in  which  so  many  different  geological  formations  occur, 
few  of  them  occupving  anv  very  extensive  region. + 

Geological  and  geographical  distribution  of  goitre  in  England 
and  Wcdes.X 

The  extent  to  which  goitre  is  associated  wdth  each  of  the 
geological  formations  of  England  will  now  be  briefly  discussed. 
The  various  geological  formations  will  be  taken  in  descending 
order. 

The  tertiary  rocks  of  England  occur  in  two  areas  forming  the 

*  I  cannot  lielp  thinkinjj  that  some  harm  has  been  done  by  those,  who, 
without  any  practical  knowledge  of  geology,  have  drawn  hasty  conclusions  from 
the  simple  comparison  of  surface  geological  maps,  and  maps  showing  distribu- 
tion of  goitre,  wiithout  taking  sufficient  care  to  consider  whence  the  water 
supply  is  derived. 

7  The  subject  has  been  investigated  by  the  Eivers  Pollution  Commission 
fi'om  whose  sixth  Eeport  I  have  derived  much  valuable  information.  I  am 
also  considerably  indebted  to  De  Eance's  "  Water-supply  of  England  and  Wales," 
Woodward's  "  Geology  of  England  and  Wales,"  and  several  other  books  on 
similar  subjects. 

%  The  following  account  of  the  distribution,  of  goitre  in  these  counti'ies  does 
not  pretend  to  be  complete  :  concerning  many  large  areas  I  have  at  present  no 
information  at  all. 


58  THE   THYROID    GLAND. 

London  and  Hampshire  basins.  Taking  the  former  first,  the 
disease  occurs  very  sparingly  over  the  Bagshot  sands  in  some  of 
the  villages  between  Aldershot  and  Chertsey,  for  example  at 
Windlesham,  Bagshot  and  Pirbright.  In  Essex  it  does  not 
occur  at  Loughton  or  Chigwell,  nor  in  the  neighbourhoods  of 
Harwich,  Colchester  or  Chelmsford. 

In  the  Hampshire  basin,  it  is  said  to  occur  at  Romsey,  but  it 
is  certainly  absent  from  the  neighbourhoods  of  Lymington,  Poole 
and  Bournemouth. 

Over  the  extensive  region  of  the  chalk,  goitre  appears  to 
prevail  to  a  very  slight  extent  but  tolerably  uniformly.  I  have 
found  a  few  cases  near  Hatfield,  Hitchin  and  Hadham  in  Hert- 
fordshire, and  at  Luton  in  Bedfordshire,  and  I  have  been  informed 
that  the  disease  occurs  to  a  slight  extent  at  villages  in  the  north 
of  Essex  (Sible  Hedingham,  AVethersfieid)  and  on  the  boi-ders  of 
Suffolk,  especially  in  parts  of  the  valley  of  the  Stour  (Cavendish 
Melford,  Sudbury  and  Xayland).  It  has  been  asserted  that  part 
of  Norfolk  is  affected.  Some  of  the  villages  a  few  miles  to  the 
west  of  Swaft'ham  are  however  certainly  not  affected.  I  am 
informed  that  goitre  occurs  also  upon  the  chalk  in  the  neighbour- 
hood of  Driffield  in  Yorkshire.  In  the  villages  situated  upon 
the  chalk  of  the  North  Downs  there  is  very  little  goitre  and  the 
same  may  be  said  of  those  upon  the  South  Downs.  The  chalk 
is  the  source  of  such  an  abundant  water  supply  that  it  is  worth 
while  to  draw  attention  to  the  rarity  of  goitre  in  connection 
with  it,  especiaUy  as  some  text-books  even  now  assert  that  it  is 
especially  prevalent  in  the  "  chalky  parts  of  England.'' 

Coming  next  to  the  upper  greensand  and  gault  which  under- 
lie the  chalk  and  come  to  the  surface  as  a  comparatively  narrow 
band,  extending  from  Devonshire  to  Yorkshire  and  also  skirting 
the  Weald  district  of  Kent,  Surrey  and  Sussex,  we  find  that  goitre 
is  rarely  present  upon  either  of  these  rocks.  The  lower  green- 
sand  area,  on  the  contrary,  is  one  upon  which  I  have  found  a 
considerable  amount  of  goitre.  In  the  south  of  Bedfordshire  it 
forms  the  low  sandy  hills  in  the  neighbourhood  of  Ampthill, 
itself  a  known  seat  of  the  disease.  I  have  seen  cases  at  Aspley 
Guise,  Ridgmount  and  Woburn — all  villages  in  this  neighbour- 
hood.    Examination  of  the  books  of  the  Bedford  Infirmary  * 

*  Kindlv  undertaken  for  me  bv  mv  friend  Dr.  Skeldino;  uf  Bedford. 


ENDEMIC   GOITRE.  59 

showed  that  a  considerable  proportion  of  the  cases  of  goitre 
treated  there  came  from  these  villages  and  from  others  such  as 
Moulsoe,  Eversholt,  and  Maulden,  all  similarly  situated.  I  have 
been  unable  to  find  any  goitre  in  many  of  the  villages  situated 
upon  lower  greensand  in  the  south  of  Surrey,  but  it  is  said  to 
occur  at  Haslemere. 

With  regard  to  the  Wealden  area,  goitre  appears  to  be 
tolerably  common  over  the  central  and  more  hilly  parts. 

Several  cases  came  under  my  notice  at  Cuckfield,  and  I  have 
heard  of  many  others  from  other  parts  of  the  same  area.  I  have 
reasons  for  believing  that  the  disease  is  distributed  tolerably 
uniformly,  although  not  very  thickly,  over  the  whole  of  the 
central  (Hastings  sand)  area  of  the  Weald.  I  have  been  told 
that  it  is  common  at  Horsham,  but  I  have  not  personally 
examined  this  district.  Villages  situated  upon  the  Weald  clay 
appear  to  be  slightly  affected.  I  found  several  cases  at  Hadlow, 
and  in  neighbouring  villages.  From  a  similar  district  further  to 
the  east,  a  small  number  of  cases  have  been  reported  to  me.  I 
have  made  personal  inquiries  at  most  of  the  villages  on  the  tract 
of  country  extending  from  near  Eastbourne  to  Steyning,  immedi- 
ately north  of  the  South  Downs.  These  villages  are  situated 
upon  greensands,  gault  and  Weald  clay.  I  saw  no  cases  of 
goitre  and  heard  of  only  an  occasional  one  here  and  there. 
Those  of  the  inhabitants  who  knew  what  ffoitre  was  ao-reed  in 
saying  it  was  much  commoner  further  north  in  the  Hastings 
sands  area. 

Underlying  the  cretaceous  strata,  and  appearing  on  the 
surface  in  this  country  to  the  west  and  to  the  north-west  of  these 
rocks,  comes  the  great  series  of  the  oolites.  It  has  been  stated 
by  most  of  those  who  have  written  upon  the  subject  of  the 
distribution  of  goitre  in  England  that  goitre  does  not  occur 
upo7i  the  oolites,  except  at  Helmsley  in  Yorkshire.  ]\ly  own 
experience  does  not  lead  me  to  endorse  this  statement.  I  have 
on  the  contrary  found  that  goitre  is  tolei'ably  common  upon 
certain  members  of  the  oolite  series,  and  is  especially  frequent 
in  the  villages  situated  just  at  the  junction  of  the  oolites  with 
the  lias. 

In  Somersetshire  it  is  prevalent  at  Chinnocks,  Stoke-under- 
Ham,  and  Chiselborough ;  the  latter  village  has  long  been  noted 


60  THE   THYROID   GLAND. 

as  a  seat  of  cretinism.  Further  north  I  have  found  it  at  Corton 
Denhani  and  neighbouring  vdlages.  It  is  said  to  be  common  at 
^Vootou-under-Edge  in  Gloucestershire.  I  have  seen  many 
cases  at  and  near  Stroud,*  and  in  many  of  the  villages  situated  on 
the  oolites  to  the  east  of  Cheltenham.  Still  further  east  I  found 
that  in  many  of  the  villages  round  Xorthleach,*  as  well  as  in 
Northleach  itself,  the  disease  was  common.  In  Yorkshire  it  is 
known  to  occur  at  Helmsley  and  I  have  been  informed  that  it  is 
found  also  in  several  villages  to  the  east  of  Easingwold.  I  have 
seen  a  few  cases  near  Malton. 

The  next  formation  that  we  have  to  consider  is  the  lias.  The 
upper  members  of  this  series  he  immediately  mider  the  oolites, 
and  goitre  occurs  in  numerous  villages  alreadv  mentioned,  just 
at  the  junction  of  the  two  formations,  being  most  common 
apparently  upon  the  sands  that  are  now  considered  to  be  the 
lowest  members  of  the  oolites.-*-  Upon  the  middle  lias,  the 
disease,  so  far  as  mv  observations  extend,  is  less  common. 

I  have  found  a  few  scattered  cases  to  the  west  of  Chiselborough 
and  Stoke-under-Ham. 

In  the  south  of  Northamptonshire  and  the  neighbouring  parts 
of  Warwickshire,  m  districts  where  the  oolites  are  absent,  I  have 
nevertheless  found  a  considerable  amount  of  goitre.  The  village 
of  Chacombe,  where  goitre  is  decidedly  prevalent,  rests  upon 
marlstone  (middle  lias).  The  Warwickshire  villages  of  Warm- 
ingtou  and  Avon  Dassett,  where  the  disease  prevails  to  a  slight 
extent,  are  situated  at  the  foot  of  hills  of  similar  rock.  !My 
friend  Dr.  Bernard  Rice  has  kindly  examined  the  outpatient 
books  of  the  Wharncliffe  Hospital  in  that  town,  in  order  to 
ascertain  the  distribution  of  the  disease  in  that  neighbourhood. 
He  found  that  out  of  twentv-two  cases  that  had  come  from 
surrounding  villages,  no  i'ewer  than  eighteen  came  from  the 
liassic  district  to  the  east  and  south-east  of  Leamington.  On 
the  other  side  of  the  town  is  the  new  red  sandstone,  and  only 
four  cases  came  from  this  district.  A  village  in  which  the  dis- 
ease appears  to  be  especially  prevalent  is  Napton,  situated  at  the 

*  Two  of  the  patients  upon  whom  I  have  operated  for  goitre  had  always  lived 
within  a  few  miles  of  Stroud  and  a  third  came  from  the  neighbourhood  of 
Xorthleach. 

t  H.  B.  "Woodward,  "  Geology  of  England  and  Wales,"  1887,  p.  287. 


ENDEMIC    GOITRE.  6l 

foot  of  a  hill  of  marlstone,  underlaid  and  surrounded  by  lower 
lias  clay  and  limestone. 

So  far  as  I  can  j  udge,  this  district  appears  to  be  fairly  typical 
of  the  distribution  of  goitre  upon  the  lower  lias.  The  disease  is 
either  absent  altogether  or  is  thinly  diffused  over  it.  It  must 
not  be  forgotten,  however,  that  in  many  parts  of  England,  as 
for  example  in  the  neighbourhood  of  Cheltenham,  the  lias  is 
thickly  overlaid  with  drift  oolite,  not  marked  upon  an  ordinary 
geological  map.  The  water  supply  in  such  regions  is  frequently 
derived  from  shallow  wells  in  this  drift  and  not  from  the  lias 
at  all. 

Upon  the  triassic  division  of  the  new  red  sandstone,  goitre 
appeal's  to  occur  very  sparingly  if  at  all.  At  West  bury -upon - 
Severn,  situated  upon  this  rock  near  the  lias,  I  could  not  hear  of 
any.  From  the  region  of  the  triassic  rocks  of  South  Derbyshire, 
it  appears  to  be  almost  absent — at  least  such  is  the  case  at 
Findern,  Newton  Solney,  Foremark  and  Repton,  according  to 
information  supplied  to  me  by  Dr.  Cronk  and  from  personal 
inquiries  made  in  this  district. 

Its  scarcity  upon  the  trias  to  the  west  of  Leamington  has 
already  been  mentioned.  Over  the  large  area  in  which  this  rock 
comes  to  the  surface  in  Nottinghamshire,  the  disease  appears  to 
occur  but  rarely. 

The  lower  division  of  the  new  red  sandstone  is  the  Permian, 
often  known  as  the  magnesian  limestone  because  a  large  pro- 
portion of  its  rocks  is  composed  of  that  material.  It  occurs  in 
this  country  chiefly  as  a  narrow  band  extending  from  North- 
umberland to  Nottingham  shire. 

It  has  long  been  a  favourite  belief  that  magnesian  limestone 
is  especially  associated  with  goitre,  but  I  doubt  whether  there 
is  much  truth  in  this.  In  part  of  the  magnesian  limestone 
area  of  Nottinghamshire  I  found  goitre  to  be  distinctly  rare. 
In  other  parts  it  appears  to  be  less  common  than  upon  the 
carboniferous  limestone.  It  is  said  to  be  common  in  the 
neighbourhood  of  Knaresborough,  in  Yorkshire.  I  ought  to 
mention  that  the  term  "  magnesian  limestone"  is  used  ffeolooi- 
cally,  to  denote  a  large  series  of  marls,  sandstones,  and  lime- 
stones, and  that  it  consists  by  no  means  wholly  of  magnesian 
limestone  in  the  chemical  or  mineralogical  sense  of  the  word. 


62  THE   THYROID   GLAND. 

Magnesian  limestone — using  the   terin   in   the  latter  sense — is 
found  in  other  rocks  besides  those  of  the  Permian  series. 

The  next  series  of  rocks  that  engages  our  attention  is  the 
carboniferous.  At  the  top  of  this  series  come  the  coal  measures, 
and  upon  them  goitre  appears  to  occur  to  a  moderate  extent.  The 
counties  best  known  to  me  in  which  this  foruiation  occurs  are 
Derbyshire  and  Yorkshire,  and  in  both  of  them  I  found  that 
goitre  was  fairly  common  upon  the  coal  measures.  I  have  also 
foLuid  it  near  Llanelly  in  Glamorganshire.  The  millstone  grit, 
on  the  contrary,  appears  to  be  much  more  free  from  the  disease. 
I  have  been  informed  that  at  Ilk  ley  goitre  does  not  occur  in 
places  upon,  or  supplied  by  water  from  this  formation,  whereas 
on  the  carboniferous  limestone  not  far  away,  the  disease  is  not 
uncommon. 

At  the  Saltaire  Hospital  in  one  year,  out  of  780  patients 
applying  for  treatment  only  four  did  so  on  account  of  goitre. 

At  Chapel-en-le-Frith,  in  Derbyshire,  I  was  informed  that 
cases  of  goitre  were  more  often  seen  in  the  districts  to  the  south- 
east of  the  town,  where  the  carboniferous  limestone  prevails, 
than  in  other  districts  where  millstone  grit  and  Yoredale  rocks 
are  found.  I  was  also  told  that  since  the  introduction  of  a  new 
water  supply  from  the  millstone  grit  goitre  has  become  less 
common. 

It  has  been  stated  that  goitre  is  common  in  the  Peak  district 
of  Derbyshire,  where  the  rocks  consist  chiefly  of  millstone  grit 
and  Yoredale  rocks  (grits,  sandstones  and  shales  with  thin  earthy 
limestones).  Upon  inquiry  at  Castleton,  upon  the  southern 
edge  of  this  district,  I  was  assured  that  goitre  was  much  less 
prevalent  in  the  Peak  district  than  on  the  carboniferous  lime- 
stones further  south.  The  millstone  grit  formation  is  the  source 
of  water  supply  to  so  many  of  the  towns  in  the  north  of  England 
that  the  absence  of  goitre  from  it  becomes  a  matter  of  consider- 
able importance. 

The  carboniferous  limestone  regions  of  England  have  been 
described  as  a  very  hotbed  of  goitre,  and  I  am  inclined  to  believe 
that  this  is  a  tolerably  accurate  statement.  Over  the  whole  of 
this  area  in  Derbyshire,  but  especially  along  the  eastern  border 
of  it,  I  found  numerous  cases,  for  example,  in  the  neighbourhoods 
of  Cromford,  Matlock,  Youlgreave,  Bakewell,  Baslow,  and  Stony 


ENDEMIC   GOITRE.  63 

Middleton.  The  same  may  be  said  of  the  region  on  the  north 
side  of  Ashbourne,  and  I  am  told  that  the  disease  is  also  common 
over  the  similar  districts  in  the  east  of  Staffordshire. 

In  Somersetshire  it  occurs,  I  am  informed,  upon  this  forma- 
tion at  Clevedon,  and  I  have  heard  of  a  number  of  cases  upon 
various  parts  of  the  carboniferous  limestone  of  the  Mendip  Hills. 
In  Northumberland,  on  the  other  hand,  it  appears  to  be  less 
common,  but  it  is  worth  noticing  that,  in  the  north  of  England, 
this  formation  loses  its  markedly  calcareous  character  and  is 
represented  largely  by  sandstones  and  shales.  In  the  Forest  of 
Dean  goitre  is  said  to  be  common,  but  I  do  not  know  whether 
upon  the  carboniferous  limestone  or  upon  the  other  rocks  of  this 
region. 

With  regard  to  the  occurrence  of  goitre  upon  Devonian  and. 
old  red  sandstone  rocks,  my  information  is  chiefly  of  a  negative 
character,  but  such  information  as  I  have  tends  to  show  that  the 
disease  occurs  but  rarely  upon  either  of  them.  At  Ilfracombe 
and  probably  over  the  north  of  Devonshire  generally,  goitre  does 
not  occur.  The  same  may  be  said  of  the  western  extremity  of 
Somersetshire.  I  am  informed  also  that  in  the  neighbourhood 
of  Talgarth,  in  Brecknockshire,  the  disease  is  not  prevalent. 

Of  the  Silurian  and  Cambrian  and  pre-Cambrian  rocks  which 
form  so  large  a  portion  of  Wales,  I  have  scarcely  any  practical 
knowledge,  and  consequently  cannot  say  much  about  the  occur- 
rence or  otherwise  of  goitre  upon  them.  The  little  information 
I  have  obtained,  how^ever,  tends  to  show  that  here  also  goitre  is 
rare.  In  Anglesea,  for  example,  I  am  informed  that  goitre  does 
not  occur  at  all  in  the  north-west  portion  in  the  neighbourhood 
of  Amlwch,  and  is  probably  absent  from  the  whole  island.  With 
regard  to  granite  and  other  igneous  rocks,  I  believe  that  they 
are  free  from  goitre  ;  at  least,  I  have  never  heard  of  any  goitre 
upon  them,  and  those  districts  of  them  that  I  have  been  able  to 
examine,  such  as  Widdicombe  on  Dartmoor,  are  quite  devoid 
of  the  disease. 

From  the  foregoing  it  will  be  seen  that  goitre  is  distributed 
over  a  very  large  surface  of  this  country.  Its  coincidence  every- 
where with  calcareous  rocks,  which  are  also  very  widely  dis- 
tributed in  England,  is  one  of  the  most  marked  features  of  its 
distribution.     It  is  not  only  upon    limestone  but    also    upon 


64  THE   THYROID    GLAND. 

calcareous  sandstones  that  goitre  is  found.  ^Vhether  it  ever 
occurs  as  an  endemic  disease  upon  non-calcareous  rocks  is  at  least 
doubtful.  The  igneous,  metamorphic,  Cambrian,  Silurian, 
Devonian,  Yoredale,  and  millstone  grit  rocks,  and  some  of  the 
non-calcareous  parts  of  the  coal  measures  and  tertiaries,  appear 
to  be  mainly  free  from  the  disease. 

Now,  speaking  generally,  the  water  derived  from  these  rocks, 
whether  it  be  upland  surface  water  or  spring  water,  or  deep  well 
water,  differs  considerably  from  water  derived  from  most  of  the 
other  rocks  in  containing  a  smaller  quantity  of  mineral  matter 
and  in  being  less  hard.  Of  eighty-one  samples  of  upland  surface 
water  derived  from  metamorphic,  Cambrian,  Silurian  and 
Devonian  rocks,  the  Rivers  Pollution  Commission  found  that 
the  average  total  solid  impurity  was  only  5.12  parts  per  100,000 
(or  3^  grains  per  gallon).  The  average  hardness  was  only  2  5. 
Water  from  the  Yoredale,  millstone  grit  and  non-calcareous 
portions  of  the  coal  measures  and  tertiary  rocks,  although  con- 
taining rather  more  total  solid  impurity  than  water  from  the 
preceding,  is  nevertheless  on  the  whole  fairly  soft,  and  contains 
rather  less  total  solid  impurity  than  that  from  the  more 
calcareous  rocks. 

That  there  is  a  general  connection  between  goitre  and  the 
amount  of  mineral  matter  in  the  drinking-water,  and  its  hard- 
ness, there  seems  good  reason  to  believe.  But  that  many 
waters  contain  a  large  amount  of  such  mineral  matter,  and  are 
very  hard,  and  yet  do  not  produce  goitre,  seems  also  to  be  true. 
Conversely,  I  believe  that  in  a  few  instances  I  have  found 
that  a  goitre-producing  water  was  not  particularly  hard.  Thus 
in  one  of  the  Derbyshire  villages  I  found  that  a  water  which 
apparently  produced  goitre  had  not  more  than  H"  of 
hardness. 

But  it  is  probable  that  goitre-producing  waters  always  contain 
a  large  amount  of  total  solid  impurity,  although  the  impurity 
may  not  necessarily  be  such  as  to  render  the  water  very  hard. 
This  statement  appears  to  be,  on  the  whole,  confirmed  by 
published  analyses  of  goitriferous  waters  in  Switzerland  and 
France. 

As  the  chief  hardening  ingi'edients  of  water  are  bicarbonates 
and  sulphates  of  lime  and  magnesia,  it  is  not  unnatural  that 


ENDEMIC    GOITRE.  65 

these  salts  should  have  been  considered  to  be  the  cause  of  goitre. 
But  examination  of  numerous  water  analyses  have  failed  to  con- 
firm these  theories. 

Another  ingredient  which  is  by  many  belie^■ed  to  be  the 
essential  cause  of  goitre  is  iron. 

This  view  has  received  the  strong  support  of  St.  Lager,  whose 
elaborate  researches  compel  one  to  receive  with  much  respect 
any  opinion  that  he  has  expressed.  At  first  sight  the  occurrence 
of  goitre  upon  many  ferruginous  sands,  such  as  those  of  the 
lower  greensand,  the  Weald,  and  part  of  the  oolite  districts, 
lends  support  to  this  view.  But,  on  the  other  hand,  I  examined 
in  Derbyshire  numerous  samples  of  water  which  undoubtedly 
produced  goitre  ;  in  the  majority  of  these  no  iron  \\hatever  wrs 
found,  in  others  onlv  the  faintest  possible  trace.  Other 
observers,  too,  have  tested  for  iron,  with  similar  negative 
results. 

It  should  be  remembered  that  in  drawing  conclusions  as  to 
the  cause  or  otherwise  of  goitre  bv  iron,  care  should  be  taken 
not  to  pay  too  much  attention  to  the  mere  presence  or  absence 
of  this  metal  in  the  rocks  upon  which  goitre  is  found.  A  rock 
may  abound  in  a  particular  metal,  but  it  does  not  follow  that 
the  water  percolating  that  rock  will  contain  any  of  the  metal, 
unless  the  latter  happen  to  exist  in  a  soluble  form,  which  is 
often  not  the  case. 

As  regards  metallic  impurities  other  than  iron,  but  more  or 
less  allied  to  it  chemically,  it  is  not  impossible  that  one  or  more 
of  them  may  be  found  to  be  the  essential  cause  of  goitre,  but 
proof  of  this  is  quite  wanting  ;  on  the  contrary  the  evidence  we 
possess  tends  to  point  in  the  opposite  direction. 

The  suggestion  that  the  cause  of  goitre  may  be  some  organic 
impurity  of  water  has,  within  the  last  few  years  especially, 
attracted  a  good  deal  of  attention,  and  received  a  certain 
amount  of  support. 

Professor  Klebs*  has  examined  microscopically  the  water 
taken  from  springs  in  goitrous  districts  of  Salzburg  and 
Bohemia,  and  has  apparently  found  in  it  numerous  micro-organ- 
isms, chiefly  Infusoria.     He  believes  that  certain  forms  called 

*  E.  Klebs,  ••  Ueber  die  Ursache  des  Kropfes,"  Ffa/j.  ined.  Woclienscltr.,  1877, 
ii.  45. 


66  THE   THYROID    GLAND. 

navicuUt  are  the  essential  cause  of  goitre.  Bircher,  following 
Klebs,  has  made  microscopical  examinations  of  the  water  derived 
from  different  geolog-ical  formations  in  the  neighbourhood  of 
Aarau.  He  examined  waters  from  springs  in  the  molasse,  Jurassic, 
triassic,  and  crystalline  rocks,  and  found  various  forms  of 
diatoms  in  them.  But  they  were  not  found  equally  in  all  the 
waters.  Some  of  them  occurred  only  in  waters  from  a  particular 
formation.  Thus  in  waters  from  granitic  areas,  and  from  the 
Jurassic  and  upper  fresh  water  molasse,  he  found  meridion  to  be 
extremely  plentiful.  But  in  water  derived  from  the  trias  and 
from  marine  molasse,  it  was  absent,  or  nearly  so.  On  the  other 
hand,  eucyonema  w^as  found  abundantly  in  waters  from  the 
formations  on  which  goitre  prevails,  while  it  was  absent  from 
those  from  the  Jurassic  and  granitic  areas,  which  are  free  from 
the  disease.  Bircher  expressly  states  that  he  does  not  maintain 
that  any  of  these  organisms  are  necessarily  the  cause  of  goitre. 
He  simply  relates  the  fact  that  different  kinds  of  diatoms  w^ere 
found  in  waters  derived  from  different  geological  formations. 

Besides  the  above-mentioned  forms  of  diatom,  Bircher 
describes  a  form  of  rod  shaped  micro-organism  that  he  found  in 
waters  from  goitrous  districts,  but  not  in  waters  taken  from 
regions  in  which  the  disease  is  not  prevalent.  He  found  them 
in  the  waters  of  Asp,  Oeschgen,  Eiken,  Mumpf  and  Habsburg 
on  the  trias  ;  also  in  those  of  Buchs,  Aarau,  Gri'michen,  Suhr, 
and  Brugg  on  marine  molasse  :  thev  were  most  numerous  in  two 
springs  at  Buchs(close  to  Aarau);  here  goitre  is  extremely  common. 
Bircher  has  searched,  without  success,  for  these  rod-shaped  bodies 
in  the  contents  of  two  goitrous  cysts  in  young  people. 

That  goitre  can  be  produced  by  water  has,  I  think,  been 
shown  by  experiments  that  have  accidentally  been  carried  out  on 
a  large  scale  upon  man  himself.  I  refer  to  the  outbreaks  of 
so-called  epidemic  goitre  that  have  been  so  often  recorded.  For 
example,  a  regiment  of  young  soldiers  has  been  quartered  in  a 
village,  and  after  a  few  months,  or  even  weeks,  a  very  large 
proportion  of  the  men  have  become  goitrous.  A  town  or 
village  has  received  a  new  water  supply,  and  shortly  afterwards 
goitre  has  broken  out  in  a  large  number  of  the  inhabitants. 
Conversely,  a  village  affected  with  goitre  has  changed  its  water 
supply,  and  goitre  has  ceased  to  occur.     On  the  continent  there 


ENDEMIC   GOITRE.  67 

are  noted  goitre  wells  to  which  young  men  resort  who  wish  to 
obtain  exemption  from  military  service.  After  drinking  the 
water  from  these  wells  for  a  few  weeks,  they  acquire  goitres 
sufficiently  large  to  enable  them  to  obtain  their  wish.*  Bircher  f 
mentions  several  springs  near  Aarau  which  have  a  local  reputa- 
tion for  producing  goitre  in  those  who  drink  of  their  waters. 
One  of  these  is  at  the  village  of  Asp  ;  another  is  at  Buren.  At 
the  latter  place  five  children  in  one  family  who  drank  from  this 
spring  all  became  affected  with  goitre. 

In  districbs  where  goitre  is  common,  not  only  man  himself 
but  also  many  of  the  lower  animals  become  affected  with  the 
disease.  It  has  been  observed  in  dogs,  cats,  horses,  cows,  pigs, 
sheep,  goats,  antelopes,  camels  and  many  other  animals. 
Cretinism,  too,  Avhich  always  exists  Avhere  goitre  is  prevalent, 
has  been  noticed  among  some  of  the  lower  animals. 

Various  attempts  have  been  made  to  produce  goitre  artificially 
in  the  lower  animals. 

More  than  thirty  years  ago,  St.  Lager  carried  out  a  series  of 
experiments  in  this  direction.  He  began  by  feeding  two  dogs 
with  sulphate  of  lime  and  carbonate  of  magnesia ;  this  experi- 
ment was  carried  on  for  six  months  with  a  negative  result.  His 
next  series  of  experiments  was  upon  guinea-pigs,  which  he  fed 
for  several  months  with  salts  of  various  metals  mixed  with  the 
animals''  ordinary  food.  He  does  not  state  exactly  what  salts 
were  used,  but  the  results  were  negative.  He  then  tried  feeding 
mice  with  metallic  sulphides  and  sulphates ;  after  three  months, 
slight  swelling  of  the  thyroid  was  noticed  in  three  of  them  ; 
these  three  had  been  fed  upon  sulphide  and  sulphate  of  iron. 
Encouraged  by  this  apparent  success,  he  tried  sulphate  of  iron 
again  upon  a  dog,  giving  several  centigrammes  a  day.  At  the 
end  of  four  months,  he  thought  that  the  thyroid  had  increased 
in  size,  but  says  that  it  was  not  prominent  enough  to  deserve 
the  name  of  goitre.  St.  Lager  alludes  to  other  experiments 
which  had  been  performed  by  Bouchardat,  with  lime  and  mag- 
nesia, and  by  Maumene  with  fluoride  of  sodium,  but  in  neither 
case  with  any  marked  success. 

*  Further  details  upon  this  subject  may  be  found  in  the  elaborate  treatises  of 
St.  Lager,  Baillarger,  Nivet,  Hirsch,  Bircher  and  others. 
J   0]).  clt.  p.  128. 


68  THE   THYROID   GLAND. 

Bircher  experimented  upon  five  puppies  three  months  old, 
feeding  them  upon  condensed  milk  diluted  with  water  taken 
from  the  spring  in  which  Bircher  found  his  characteristic  micro- 
organisms. At  the  end  of  five  months,  the  animals  were  killed 
and  it  was  found  that  their  thyroids  had  not  undergone  any 
enlargement. 

Another  series  of  experiments  was  carried  on  in  1890,  for 
nine  months,  by  my  brother,  Mr.  Edward  E.  Berry,  F.C.S.,  and 
myself.  We  took  four  sets  of  guinea-pigs.  To  the  first  set  we 
gave  a  mixture  of  various  salts  of  lime,  magnesia,  potash,  and 
soda  ;  the  salts  chosen  were  those  obtained  by  the  analysis  of 
waters  from  two  districts  in  Auvergne  where  nineteen  and  ten 
per  cent,  respectively  of  the  male  popidation  are  afi'ected  with 
goitre.  To  the  second  set  we  gave  sulphate  of  lime  only  ;  to  the 
third  carbonate  of  iron  in  the  form  of  saccharated  carbonate. 
The  fourth  set  formed  simply  a  control  series  of  experiments 
and  received  nothing  but  their  ordinary  food  and  drink.  The 
animals  were  all  weighed  accurately  every  few  weeks,  and  the 
doses  of  salts  regulated  in  proportion  to  the  weights  of  the 
animals.  After  death  each  thyroid  gland  was  weighed  accurately 
and  subsequently  examined  microscopically.  The  results  were 
entirely  negative  as  far  as  the  production  of  goitre  is  concerned, 
but  they  tend  at  least  to  show  that  neither  sulphate  nor  carbonate 
of  lime,  nor  carbonate  of  magnesia,  nor  carbonate  of  iron  is 
capable  of  producing  goitre  in  guinea-pigs.* 

Lustig  and  Carle  have  published  some  interesting  and  careful 
experiments  upon  the  artificial  production  of  goitre  in  the  lower 
animals.f  They  made  use  of  water  from  certain  infected  parts  of 
the  valley  of  Aosta  in  North  Italy.  The  subjects  of  the  experiments 
were  a  young  horse  and  several  dogs.  The  horse  after  drinking 
for  several  weeks  water  suspected  of  being  capable  of  producing 
goitre,  developed  a  slowly  progressive  and  perfectly  evident 
swelling  of  one  thyroid.  This  was  removed  by  operation  and 
the  experiment  with  water  was  continued.  After  some  weeks 
the  remaining  thyroid  became  still  larger.     After  the  adminis- 

*  Fui'tlier  details  of  these  experiments  will  be  found  in  the  Brlt'isli  Medical 
Jovrnal  for  June  13,  1891. 

t  "  Sull  .■Mi()log;ia  del  gozzo  endemico."  Lustig  e  Carle,  6-'/('r«.  d.  R.  Accad.d. 
med.  dl  Tormo,  1890,  p.  689-717. 


ENDEMIC   GOITRE.  69 

tration  of  this  water  bad  ceased,  the  size  of  the  thyroid  gradually 
diminished  until  eventually  the  swelling  could  no  longer  be  felt. 

Thirteen  dogs,  mostly  young,  were  given  water  from  the 
Buthier  stream,  a  suspected  source  of  goitre.  In  one  of  these 
and  perhaps  in  another,  some  swelling  of  the  thyroid  was 
produced.  From  the  first  of  these  animals  the  enlarged  left 
thyroid  was  then  removed  and  the  experiment  continued.  A 
month  later  the  right  thyroid  was  visibly  enlarged.  The  ad- 
ministration of  natural  Buthier  water  was  then  discontinued 
and  the  same  water  freed  from  bacteria  was  given  instead.  The 
result  was  that  the  swelling  gradually  diminished  and  finally 
became  imperceptible.  In  some  of  the  thirteen  animals,  swelling 
of  the  lymphatic  glands  was  noticed  and  in  some  of  them  diarrhoea 
occurred. 

Ten  young  and  healthy  dogs  treated  solely  with  Buthier 
water,  boiled  and  filtered,  did  not  show  any  alteration  in  their 
thp'oids,  A  young  puppy  born  in  an  infected  region,  and  the 
subject  of  a  considerable  goitre,  was  removed  to  a  region  free 
from  the  disease.  Water  supposed  to  be  capable  of  producing 
goitre  was  given  to  it  and  the  goitre  became  larger ;  the  ad- 
ministration was  discontinued  in  favour  of  filtered  water  and  the 
goitre  disappeared  completely. 

These  experiments,  if  confirmed,  tend  to  prove  that  goitre 
can  be  produced  artificially  by  the  administration  of  certain 
waters.  Further,  boiling  and  filtration  seem  to  deprive  the 
water  of  its  goitre-producing  elements. 

Further  experiments  in  the  same  direction  and  upon  a  larger 
number  of  animals  are  however  necessary  before  they  can  be 
considered  conclusive.  The  authors  themselves  seem  fully  aware 
of  this  and  speak  with  praiseworthy  hesitation. 

Dr.  Grasset  ''•'  has  recently  stated  that  the  cause  of  goitre  is  to 
be  found  in  certain  hsematozoa  which  he  has  found  in  the  blood 
of  patients  recently  affected  with  the  disease.  This  micro- 
organism is  said  to  resemble  Lavaran's  ha?matozoon  found  in 
ague,  but  differs  from  it  in  certain  minor  details.  Grasset's 
observations  are  interesting  but  require  confirmation. 

(4)  Habits  of  Life,  Exertion,  Strain,  etc. — A  popular  theory 

attributes  goitre  to  violent  muscular  exertion  such  as  carrying 

*  La  France  Medicale,  .July  IS,  1898,  and  Glasgow  Medical  JuurnaJ.  Jau.  1899. 


70  THE    THYROID    GLAND. 

weights  on  the  head,  straining,  couohing,  and  blowing  wind 
instruments.  It  is  at  least  doul)tful  whether  any  of  these 
habits  ever  cause  enlargement  of  a  previously  healthy  gland. 

The  habit  of  carrying  weights  on  the  head  is  common  in 
many  countries  where  goitre  exists  and  also  in  many  Avhere  it 
does  not.  The  disease  frequently  shows  itself  in  quite  young 
children  who  have  never  can'ied  upon  their  heads  anything 
heavier  than  a  hat.  I  have  several  times  examined  large  numbers 
of  school  children  in  affected  districts*  and  found  a  considerable 
proportion  of  them  affected  with  the  disease.  The  occurrence 
of  the  disease  in  the  lower  animals  is  another  proof  that  carrying 
weights  on  the  head  is  not  the  cause  of  goitre. 

It  is  possible  that  although  muscular  exertion  does  not  itself 
produce  goitre  it  may  aggravate  the  disease.  A  thyroid  gland 
already  somewhat  enlarged  may  be  injuriously  pressed  upon  by 
^■iolent  action  of  the  muscles  of  the  neck.  In  this  manner 
extravasations  of  blood  within  the  gland  may  be  produced  and 
cysts  may  be  formed.  Nearly  all  very  large  goitres  contain 
cysts,  and  it  is  possible  that  some  of  them  may  have  originated 
in  the  manner  described. 

Intermarriage  as  a  cause  of  goitre  is  hardly  worthy  of  serious 
discussion.  Intermarriage  is  doubtless  common  in  many  isolated 
villages  where  goitre  abounds  but  is  equally  noticeable  in  many 
similar  villages  where  the  disease  is  quite  unknown. 

(5)  Heredity  is  supposed  by  many  to  play  an  important  part 
in  the  causation  of  goitre.  Undoubtedly  goitre  is  often  found 
to  occur  in  many  members  of  one  family.  Numerous  instances 
in  which  every  member  of  a  family  was  affected  with  goitre 
have  been  found  by  myself  both  in  Switzerland  and  in  this 
country ;  also  many  instances  of  goitre  existing  for  generations 
in  the  same  family. 

But  such  facts,  however  numerous  they  may  be,  do  not  afford 
proof  that  mere  heredity  is  in  anv  way  responsible  for  the 
disease.  There  is  good  reason  to  believe  that  the  cause  that 
produced  the  disease  in  one  member  of  a  family  caused  it  in 
all  the  others.  It  is  well  knoMU  that  the  apparent  heredity 
of  goitre  is  most  marked  in  places  where  the  endemicity  is 
highest. 

*  e.fj.,  at  Triora  in  X.  Italy,  and  at  Clii.selboroii2:li  in  Somersetshire. 


ENDEMIC    GOITRE.  71 

In  order  to  place  beyond  dispute  the  hereditary  nature  of 
goitre,  it  must  be  shown  that  the  goitre  in  the  child  is  not  due 
to  the  influence  of  the  same  exciting  causes  that  produced  it  in 
the  parent.  It  is  obvious  that  so  long  as  we  are  in  doubt  as  to 
the  exact  nature  of  the  goitre-producing  poison,  so  long  will  it 
be  difficult  to  prove  definitely  that  the  disease  is  cr  is  not 
hereditary.  Nevertheless  the  evidence  that  we  at  present  possess 
tends  to  show  that  heredity  ought  not  to  be  considered  as  one 
of  the  probable  causes  of  goitre.  Although  mere  heredity 
cannot  be  considered  to  be  a  cause  of  goitre,  it  is  conceivable 
that  some  hereditary  tendency  may  render  a  person  more  suscep- 
tible to  the  influence  of  the  goitre-producing  poison,  but  there 
is  little  or  no  evidence  of  this. 

Summing  up,  there  can  be  no  doubt  that  climatic  and  atmo- 
spheric conditions  have  little  or  no  share  in  the  causation  of 
goitre.  That  want  of  air  and  sunshine  has  absolutely  nothing 
whatever  to  do  with  it  is  equally  certain.  Habits,  such  as 
carrying  weights  on  the  head,  violent  exertion  and  the  like,  play 
but  a  secondary  part  in  the  production  of  the  disease.  That 
heredity  is  a  cause  of  goitre  is  extremely  doubtful.  Interniarriaice 
has  certainly  no  share  in  its  causation. 

That  there  exists  some  definite  relation  between  endemic 
goitre  and  some  poison  in  the  soil  upon  which  it  is  found  is 
tolerably  clear,  and  there  can  be  no  doubt  that  in  the  vast 
majority  of  cases  drinking  water  is  the  vehicle  by  means  of 
which  that  poison  obtains  access  to  the  body.  Such  water  is 
usually,  if  not  always,  derived  from  calcareous  soils,  but  it  is 
probable  that  the  goitre-producing  poison  is  not  a  salt  of  lime 
or  magnesia.  It  has  not  yet  been  proved  satisfactorily  that  any 
sail  of  iron  is  the  essential  constituent.  The  same  mav  be  s;iid 
of  micro-oru;anisms. 


CHAPTER   VI. 

SYxMPTOMS  AND  DIAGNOSIS  OF  THYROID  ENLARGE- 
MENTS—PHYSICAL SIGNS. 

Mobility — Shape — Size — Position  with  regard  to  muscles,  great  vessels, 
sternum  —  Pulsation  —  Diagnosis  from  aneurism  —  Consistence  — 
Pressure  effects,  on  veins,  recurrent  laryngeal  nerve,  sympathetic, 
cervical  and  brachial  plexuses,  larynx  and  trachea,  oesophagus  and 
pharynx. 

The  thyroid  gland  may  be  the  seat  of  various  diseases,  each  of 
which  has  some  chai'acters  peculiar  to  itself.  There  are  many 
characters,  however,  which  are  more  or  less  common  to  all  forms 
of  enlargement  of  this  organ. 

These  will  be  discussed  in  this  and  in  the  following; 
chapter. 

In  most  cases  it  is  not  a  difficult  matter  to  determine  whether 
a  given  swelling  in  the  neck  does  or  does  not  belong  to  the 
thyroid.  Occasionally,  however,  the  most  marked  characteristics 
of  a  thyroid  swelling  are  absent,  or  are  closely  simulated  by  other 
conditions,  and  thus  mistakes  may  occur. 

The  diagnosis  of  an  enlargement  of  the  thyroid  is  made  partly 
by  examination  of  the  physical  signs  of  the  swelling  itself  and 
partly  by  the  pressure  effects  which  it  exerts  upon  surrounding 
structures.  To  a  very  small  extent  the  effect  of  the  disease 
upon  the  function  of  the  gland  may  produce  signs  and  symptoms 
which  are  of  some  help  in  diagnosis. 

Physical  Signs. — Among  these  we  have  to  consider,  (1) 
Mobility;  (2)  Shape  ;  (3)  Size;  (4)  Position  ;  (5)  Pulsation  ;  (6) 
Consistence. 

(1)  Mobility. — Owing  to  the  close  connection  already  described 
which  exists  between  the  larynx  and  the  thyroid  gland,  the 
latter  follows  the  former  in  all  its  movements.     Hence  one  of  the 


SYMPTOMS   AND    DIAGNOSIS.  73 

most  important  signs  of  a  thyroid  tumour  is  that  if  rises  and 
falls  loitli  the  larynx  and  trachea  during  deglutition. 

In  the  great  majority  of  cases  the  presence  of  this  sign  alone 
is  sufficient  to  enable  us  to  form  a  correct  diagnosis  of  the  thyroid 
nature  of  the  swelling  under  examination.  Care  must  be  taken, 
however,  not  to  rely  too  implicitly  in  all  cases  upon  this  sign 
only.  For  there  are  two  sources  of  fallacy  with  regard  to  it, 
that  may  lead  to  mistakes. 

In  the  first  place  a  swelling  which  is  not  of  thyroid  origin 
may  present  the  above  sign ;  and  in  the  second  place  one  which 
is  really  thyroid  may  not  present  it. 

The  cases  which  come  into  the  former  category  are  fortunately 
rare ;  and  most  of  them  are  generally  easily  distinguished, 
because  the  tumour  will  be  found  not  to  occupy  exactly  the  same 
situation  as  a  tumour  of  the  thyroid. 

Such  are  cysts  of  the  subhvoidean  region  which  lie  in  the 
middle  line  on  a  level  with  the  upper  border  of  the  thyroid 
cartilage.  It  is  possible  that  a  very  large  cyst  of  this  kind  might 
be  mistaken  for  a  tumour  of  the  upper  horn,  or  of  the  pyramid 
of  the  thyroid,  but  its  high  situation  in  the  middle  line  would 
almost  invariably  be  quite  enough  to  distinguish  it.* 

In  1893  I  saw  with  Mr.  Bowlby  at  St.  Bartholomew's  Hospital 
a  man  who  had  a  rounded  prominent  swelling  covering  the  whole 
of  the  front  of  the  thyroid  cartilage  and  firmly  fixed  to  it.  It 
was  almost  exactly  in  the  middle  line,  and  at  first  sight  closely 
resembled  a  subhyoidean  bursa.  A  careful  examination,  how- 
ever, showed  that  it  was  connected  with  the  left  lobe  of  the 
thyroid  gland. 

Tumours,  both  innocent  and  malignant,  spi'inging  from  the 
larynx  or  trachea  and  growing  outwards,  may  occasionally 
simulate  swellings  of  the  thyroid  gland.  They  are,  however, 
rare. 

Mr.  Percy  Furnivall  has  kindly  given  me  notes  of  the  follow- 
ing case  that  came  under  his  notice  in  1893 : 

''  A  gentleman  aged  55  had  had  for  thirteen  years  a  swelling  on 
the  right  side  of  the  neck.  In  1887  he  had  seen  Sir  Morell 
Mackenzie,  who  wished  to  aspirate  and  inject   it.     Later  he  was 

*  See  a  paper  by  Larrey,  Gaz.  d.  Hoj).,  1853,  pp.  212.  22.5. 


74  THE    THYROID    GLAND. 

seen  by  another  surgeon  who  also  considered  that  it  was  •  probably 
a  thyroid  cyst.'  On  the  right  side  of  the  neck,  close  to  the  middle 
line,  was  a  sausage-shaped  swelling,  situated  partly  under  the 
sterno-mastoid  at  its  lower  end.  The  upper  part  lay  between  that 
muscle  and  the  middle  line  and  extended  nearly  up  to  the  lower 
jaw.  It  was  well  defined,  very  soft  and  elastic,  and  apparently 
fluctuated.  //  mored  distinctly  with  the  larynx  on  deglutition.  It  was 
removed  by  operation  and  was  found  to  be  a  lipoma  attached  to  the 
side  of  the  thyroid  cartilage." 

Several  cases  have  come  under  my  own  notice  in  which  malig- 
nant growths  springing  from  the  lower  end  of  the  pharynx  and 
upper  end  of  the  oesophagus  were  verv  difficult  to  distinguish 
from  growths  in  the  thyroid  gland  itself. 

Tracheal  hernia  is  said  by  Norris  Wolfenden  and  others  to 
simulate  bronchocele  very  closely. 

Dr.  Wolfenden  *  has  given  an  account  of  three  cases  supposed 
to  be  of  this  nature,  and  remarks  that  "  the  practitioner  is  not 
likelv  to  recoo-nise  the  true  state  of  affairs  unless  he  has  caused 
the  patient  to  voluntarily  distend  the  tumour." 

On  the  other  hand  it  should  be  remembered  that  some  goitres 
are  visible  onlv  when  the  patient  makes  an  expiratory  effort. 
Both  Wolfler  and  myself  have  had  to  operate  upon  such  cases.  I 
am  disposed  to  agree  with  Wolfler,  who  is  sceptical  about  the 
existence  of  tracheal  hernia  resembling  goitre.  He  states  t  that 
one  of  Wolfenden's  cases  was  subsequentlv  pro^■ed  by  operation 
to  be  a  true  goitre  and  not  a  tracheal  hernia. 

Necrosis  of  a  portion  of  one  of  the  laryngeal  cartilages  may 
cause  an  abscess  which  sometimes  can  scarcely  he  distinguished 
from  a  cyst,  suppurating  or  not,  of  the  thyroid  gland. 

Kohn  I  has  recorded  a  remarkable  instance  of  such  a  case  : 

"  A  woman  had,  in  the  region  of  the  right  lobe  of  the  thyroid 
gland,  a  swelling  which  was  taken  to  be  a  chronic  abscess  of  that 
organ.      But    after    evacuation   of  the   pus   it   was   found  that    the 

*  Jvurnal'Of  Laryngology,  1888,  p.  99.  See  also  a  long  and  very  complete 
paper  on  the  same  subject  by  Dr.  J.  H.  Petit  in  Reviie  lie  CItlnirgie,  Paris, 
February,  March,  May  and  June  1889. 

f  "  Die  chirm'gische  Behandlung  des  Kropfes,"  Berlin,  1890,  ii.  p.  2. 

X  "  Ceber  Strumitis  und  ThjToiditis,"  Allgem.  Wien.  3Ied,  Ze'itung.  1885, 
p.  215. 


■     SYMPTOMS    AND    DIAGNOSIS.  75 

abscess  was  due  to  necrosis  of  one  of  the  laryngeal  cartilages  and 
was  wholly  unconnected  with  the  thyroid  gland."  * 

Various  swellings  having  their  origin  in  tissues  external  to  the 
larynx  and  trachea  may  become  adherent  to  them  secondarily 
and  so  participate  in  their  movements.  Such  are  affections  of 
the  cervical  lymphatic  glands.  Some  years  ago  while  dissecting 
out  a  thyroid  gland  from  a  dead  body  in  the  post-mortem 
room  of  St.  Bartholomew's  Hospital,  I  came  upon  an  oval  swell- 
ing, close  to  the  lower  part  of  the  right  lobe ;  at  first  sight  this 
appeared  to  be  an  abscess  in  the  thyroid  gland.  It  was  firmly 
connected  with  the  trachea  and  the  recurrent  laryngeal  nerve 
was  spread  out  over  it.  There  can  be  no  doubt  that,  had  it 
been  detected  during  life,  it  would  have  been  found  to  follow 
the  trachea  in  all  its  movements,  and  it  would  almost  certainly 
have  been  taken  for  a  thyroid  swelling.  It  was,  however,  simply 
a  chronic  abscess  that  had  originated  in  one  of  the  cervical  lym- 
phatic glands. 

In  1895  I  saw  a  patient  of  ]\Ir.  Bowlby's,  a  young  man  with  a 
mass  of  enlarged  tuberculous  glands  adherent  to  the  side  of  the 
larynx  ;  the  resemblance  to  a  tumour  of  the  thyroid  was  con- 
siderable. 

In  St.  George's  Hospital  ^Museum  is  a  specimen  of  a  sebaceous 
cyst  situated  immediately  in  front  of  the  larynx.-*"  During  life 
it  had  been  mistaken  for  a  cyst  of  the  thyroid,  and  had  been 
injected  with  perchloride  of  iron  with  a  fatal  result. 

I  have  seen  one  case  in  which  a  dermoid  cyst  lay  immediately 
in  front  of  the  larynx  and  followed  its  movements  during  deglu- 
tition. 

We  come  now  to  the  second  class  of  cases,  those  that  fail  to 
move  with  the  lar^^nx  during  deglutition  although  they  are  of 
thyroidal  origin. 

This  may  occur,  first,  when  the  bulk  of  the  tumour  is  so  great 
as  either  to  conceal  or  to  mechanically  prevent  the  movements  of 
the  larynx  and  trachea ;  and,  secondly,  when  the  tumour  is  pre- 
vented from  moving  by  reason  of  its  adhesions  to  neighbouring 

*  A  somewhat  similar  case  came  under  my  own  notice  some  years  ago ;  this 
was  one  in  which  a  swelling  caused  by  perichondritis  of  the  thyi'oid  cartilage 
had  been  mistaken  by  the  surgeon  for  tumour  of  the  thjToid  gland. 

f  New  Catalogue  Xo.  2lA. 


76*  THE   THYROID    GLAND. 

parts.  Malignant  disease  and  inflammation  are  the  most  common 
causes  of  such  adhesion. 

In  the  case  of  the  patient  depicted  in  Fig-.  82  deglutition 
failed  to  make  the  huge  tumour  rise  as  a  whole.  It  did  cause, 
however,  what  is  an  almost  equally  valuable  sign,  namely  a 
peculiar  shake  felt  in  the  tumour.  The  tumoiu"  was  tilted 
forwards  each  time  that  the  larynx,  to  which  it  was  attached 
posteriorly,  attempted  to  rise. 

In  cases  then  of  large  tumours  that  do  not  rise  with  the 
larynx  during  deglutition  attention  should  be  directed  to  the 
shaking  or  tilting  caused  by  this  action. 

Malignant  tumours  in  their  later  stages  frequently  become 
quite  fixed.  I  have  seen  several  cases  both  in  my  own  practice 
and  in  that  of  others,  in  which  such  tumours  were  firmly  fixed  to 
the  vertebral  colunm. 

In  September  1885,  by  the  kindness  of  Dr.  Reece,  then  acting 
as  one  of  the  medical  officers  at  the  Kensington  Infirmary,  I  had 
the  opportunity  of  examining  a  case  of  what  we,  at  first,  sup- 
posed to  be  a  tumour  of  the  thyroid  gland.  The  patient  was 
an  elderly  woman  who  had  a  hard  oval  mass,  of  the  size  and 
shape  of  a  goose's  egg,  apparently  exactly  in  the  position  of 
the  right  lobe  of  this  gland.  It  extended  from  near  the  middle 
line  of  the  neck  to  beyond  the  outer  border  of  the  sterno- 
niastoid.  It  touched  the  larynx  and  trachea  when  these  were 
in  their  natural  position,  but  it  was  found  possible  to  push 
them  considerably  to  the  left  of  the  middle  line  without  dis- 
placing the  tumour.  Indeed  a  finger  could  be  laid  in  the  groove 
thus  produced  between  them.  The  tumour  did  not  appear  to 
move  during  deglutition.  For  these  two  reasons,  then,  it  was 
concluded  that  the  tumour  was  not  of  the  thyroid  gland.  No 
operation  was  deemed  advisable.  A  few  days  later  the  patient 
died,  and  on  making  a  post-mortem  examination,  it  was  found 
that  the  tumour  was  a  mass  of  malignant  growth  (probably 
starting  in  a  lymphatic  gland),  secondary  to  disease  of  the 
mediastinum.  The  thyroid  gland  itself  was  small  and  had 
been  flattened  between  the  larynx  and  the  growth.  The  latter 
had  displaced  the  carotid  artery  and  internal  jugular  vein  to 
the  outer  side. 

It  should  be  remembered,  therefore,  that  a  movable  tumour 


SYMPTOMS   AND    DIAGNOSIS.  77 

of  the  thyroid  gland  ought  to  follow,  not  only  the  vertical  but 
also  the  lateral  movements  of  the  larynx  and  trachea. 

Large  masses  of  malignant  growth  may  be  found  in  the  neck 
Avhich  are  adherent  to  the  larynx  and  trachea  and  surrounding 
parts.  Occasionallv  in  such  cases,  it  may  be  difficult  to  say 
whether  the  growth  is  primarily  of  the  thyroid  gland. 


Figs.  34,  35  and  36. — A  large  Bilateral  Parenchymatous  Goitre. 

The  rig-ht  and  central  lobes  were  removed  by  extirpation  from  a 
woman  aged  52.  {See  Fig.  37.)  The  tumour  removed  weighed  3  lbs. 
1  oz.,  and  is  now  in  the  Eoy.  Free  Hosp.  Museum,  Xo.  xxii.  19.  (See 
also  Appendix,  Case  119,  p.  352.)     (From  pbotogTaplis  by  Dr.  Image.) 

A  few  years  ago  I  had  a  case  in  the  Roval  Free  Hospital 
illustrating  this  point.  A  small  child  had  a  large  mass  of 
lympho-sarcoma  in  the  left  side  of  the  neck.  The  larynx  and 
trachea  were  displaced  to  the  right  and  so  much  buried  in  the 
tumour  that  it  was  difficult  to  ascertain  Avhether  they  moved  on 
deglutition  or  not.  The  tumour  might  easily  have  been  mis- 
taken for  a  sarcoma  of  the  thyroid  gland. 


78 


THE   THYROID    GLAND. 


W.  Osier  has  recorded  a  case  of  lympho-sarconia  of  the  deep 
cervical  o^lands,  involving-  the  thyroid  and  simulating  goitre.* 

Wolflerf  records  a  case  in  which  a  tumour  of  the  right  lobe 
of  the  thyroid  was  mistaken  by  Professor  Billroth  for  a  lym- 
phoma. It  was  not  until  the  operation  for  its  removal  was  being 
performed,  that  the  thyroidal  nature  of  the  tumour  was  dis- 
covered.    In  the  notes  of  this  case  it  is  stated  that  there  were 


Fio.  3o. — For  ik'scription  si'u  pp.  7  7  ami  352. 

two  tumours,  each  nearlv  as  large  as  a  goose's  egg,  and  they 
were  onlv  slightlv  movable.  It  was  probably  the  absence  of  the 
usual  mobility  of  a  thyroid  tumour  that  led  to  the  error  in 
diagnosis. 

We  will  now  consider  some  of  the  other  less  important  signs 
and  endeavour  to  ascertain  their  value  from  a  diagnostic  point 
of  view. 

*  JTuntrcal  Gen.  Hn.y).  Bep.  1880,  i.  340. 

J  '•  Uebei-der  Entwickelung  und  den  Ban  des  Kropfe.s."  Anton  Wolfler,  Arrh. 
f.  Jdln.  C/iir.,  Berlin,  1883,  vol.  xxix.  p.  788. 


SYMPTOMS   AND   DIAGNOSIS.  79 

The  shape  of  an  enlarged  thyroid  may  be  very  characteristic 
or,  on  the  other  hand,  it  may  have  no  diagnostic  value  what- 
ever. When  the  gland  is  enlarged  uniformly  as,  for  example, 
in  the  early  stage  of  the  simple  parenchymatous  form  of  goitre 
it  presents  an  appearance  similar  in  shape  to  that  of  the  normal 
thyroid  gland.  Allusion  has  already  been  made  to  the  resem- 
blance which  the  latter  bears  to  a  horseshoe,  with   concavity 


Fig.  36. — For  ilescviptiou  see  pp.  77  and  352. 

upwards.  But  every  deviation  from  this  normal  typical  shape 
may  be  met  with  when  the  gland  is  enlarged  asymmetrically, 
by  the  formation  of  a  tumour  or  tumours  within  it.  A  portion 
only  of  the  gland  may  be  enlarged  and  the  resulting  tumour 
will  then  probably  present  a  more  or  less  round  or  oval 
shape. 

The  size  of  a  thvroid  tumour  may  be  very  great ;  it  may  even 
attain  that  of  a  man's  head. 

It  is  probably  among  the   cases   of  cystic   disease  that  the 


80  THE   THYROID    GLAND. 

largest  goitres  are  to  be  found.  Alibert\s  cases*  are  among  the 
largest  with  which  I  am  ac(|uainted.  Keser  f  describes  a  goitre 
removed  by  Professor  Socin  at  Basle  ;  it  was  as  large  as  a  man's 
head,  and  came  down  in  front  of  the  sternum  to  below  the  level 
of  the  xiphoid  process. 

The  largest  goitres  which  have  come  under  my  own  notice 
during  life,  are  represented  in  Figs.  34,  39,  46  and  82. 


Fig.  37. — The  pi-ccetliiig,  two  moiitlis  aftci-  Extirpation  of  tlio  wliole  of 
tlie  right  and  middle  lobes.  (See  Appendix,  Casell9,  p.  352.)  (From  a 
photograph  by  Dr.  Image. ) 

The  degree  of  prominence  also  varies  considerably.  Some 
tumours  present  scarcely  any  external  swelling,  others  form  huge 
projecting  masses  which  may  be  more  or  less  pedunculated,  and 
may  even  hang  down  over  the  front  of  the  chest  for  a  consider- 
able  distance.      Instances    of    huge  goitres,  extending   as   far 

*  "  Nosologic  Xaturelle,"  Paris,  1817,  i. 

f  Samuel  Keser,  "  L'enucleation  ou  extirpation  inti-a-glandulaire  du  goitre 
parenchymateux,"'  Paris,  1887,  p.  20. 


SYMPTOMS    AND    DIAGNOSIS. 


SI 


downwards  as  the  waist  have  been  figured  bv  Alibert.*  In  oiie 
of  these,  the  tumour  is  curiously  elongated  and  narrow,  and 
unlike  any  other  that  has  yet  come  before  my  notice. ••■ 

Position. — The  position  of  a  thyroid  swelling  naturally  differs 
according  to  the  part  of  the  gland  involved. 

The  swellino;  may  be  in  the  middle  line  of  the  neck.     This  is 


Fig.  38. — A  "Woman,  aged  38,  yritli  a  Bilateral  Goitre.  Tlie  right  lobe, 
wliicli  contained  a  solid  adenoma  weighing-  7j  ounces,  estended  deeply 
behind  the  sternum  and  right  clavicle,  and  was  extirpated  on  account 
of  severe  dvspnoe:!.     (See  Appendix,  Case  .50,  p.  346.) 

the  case  when  the  enlargement  affects  either  the  isthmus  alone 
(which  is  exceedingly  rare),  or  the  whole  gland,  including  the 
isthmus. 


*  Alibert,  "  Xosologie  Xaturelle,"  i.  p.  466,  Plates  C  aud  D. 

t  The  same  author  also  alludes  to,  but  does  not  figure,  a  case  in  which  the 
tumour  was  cylindrical  and  tapering  and  reached  as  far  down  as  the  middle  of 
the  thigh.  "  Formee  comme  un  long  cylindre  qui  seprolougeoit  jusiiu'a  la  paitie 
nioyenne  de  la  cuisse." — "  Xosologie  Xaturelle,"'  p.  468. 

F 


82 


THE   THYROID   GLAND. 


^  3.  3 
"  "3  ~ 


5    2    d  Ji-i 


■^  ~  s  '^ 


r   r-    >> 


SYMPTOMS   AND    DIAGNOSIS.  83 

It  should  be  borne  in  mind  also,  that  a  swelling  situated  in 
the  lower  part  only  of  one  lateral  lobe  will  often  push  the 
trachea  over  to  the  opposite  side  to  such  an  extent  that  the 
tumour  itself  occupies  a  position  in  the  middle  line  of  the  neck. 
Such  a  tumour  may  closely  simulate  an  enlargement  of  the 
isthmus  itself  and  is  frequently  mistaken  for  this.  It  is  a 
very  common  condition.  The  correct  diagnosis  is  easily  made 
by  a  careful  exaiiiination  of  the  exact  position  of  the  larynx  or 
trachea.     {See  Figs.  43,  55  and  Qo.) 

Very  frequently,  however,  a  thyroid  swelling  lies  more  to  one 
or  other  side  of  the  middle  line,  one  lateral  lobe  alone  of  the 
gland  being  enlarged,  or  the  enlargement  affecting  one  lobe  more 
than  the  other.     {See  Figs,  87,  103.) 

Often,  only  a  portion  of  one  lobe  is  enlarged  bv  the 
presence  within  it  of  a  cystic  or  solid  tumour.  Such  a 
tumour  may  be  situated  in  almost  any  part  of  the  front  of 
the  neck. 

It  may  even  lie  mainly  or  entirely  ^^■ithin  the  thorax 
behind  the  upper  part  of  the  sternum.  In  this  case,  the 
tumour  has  grown  downwards  from  the  lowest  part  of  the 
gland. 

On  the  other  hand  a  thyroid  tumour  may  involve  only  the 
apex  of  the  superior  horn  of  the  gland  and  lie  entirely  at  the 
upper  part  of  the  neck  near  the  angle  of  the  jaw.  Of  this  I 
have  seen  several  cases,  from  one  of  which  the  photograph 
shown  in  Fig.  41  was  taken. 

It  is  important  to  remember  that  a  swelling  of  thyroidal 
origin  may  occasionally  occupy  such  a  situation.  This 
high  position  is  frequently  a  source  of  erroneous  diagnosis. 
Tumours  in  such  a  position  are  often  mistaken  for  lym- 
phatic glandular  swellings  or  even,  as  in  one  case  that  came 
under  my  notice,  for  a  tumour  of  the  submaxillary  salivary 
gland. 

In  July  1894, 1  operated  with  Dr.  Eminson  at  Scotter,  Lincoln- 
shire upon  a  man  of  30  who  had  had  for  many  years  a  globular 
swelling  nearly  two  inches  in  diameter  which  lay  directly  in 
front  of  the  thyroid  cartilage  and  hyoid  bone  and  slightly  to  the 
right  of  the  middle  line.     Its  lowest  border  was  on  a  level  with 


84 


THE   THYROID    GLAND. 


the  crico-thyroid  membrane,  that  is,  wholly  above  the  thyroid 
isthmus.  The  lateral  lobes  of  the  thyroid  gland  were  not 
enlarged.     A  process  of  thyroid  gland  found  at  the  operation 

to  run  up  from  the 
tumour  behind  the 
hyoid  bone,  together 
with  the  subsequent 
microscopic  examina- 
tion of  the  cyst  wall,_ 
proved  the  tumour  to 
have  originated  in  the 
thyroid  pyramid.  The 
patient  made  an  excel- 
lent recovery. 

In  February  1895,  a 
young  woman  was  sent 
to  me  by  Miss  Aldrich 
Blake,  M.D.,  on  account 
of  an  oval  tumour  as 
large  as  a  pigeon's  ef^g 
situated  directly  over 
the  thyroid  cartilage  and 
slightly  to  the  right  of 
the  middle  line.  On 
account  of  a  slight  band 
of  tissue  which  could 
be  felt  passing  down- 
wards from  the  tumour 
to  the  inner  side  of  the  right  thyroid  lobe,  the  tumour  was 
recognised  as  one  of  the  thyroid  pyramid. 

It  may  be  noticed  that  in  both  these  cases  the  tumour  lay 
exactly  in  the  line  of  the  right  thyroid  pyramid. 

Sometimes  enlarged  portions  of  a  thyroid  gland  occupy  still 
more  curious  situations.  In  a  case  of  multilocular  cystic  goitre 
shown  to  me  at  St.  Bartholomew's  Hospital  by  Mr.  Butlin, 
besides  a  swelling  of  the  whole  left  lobe  of  the  gland  there 
existed  a  portion  which  appeared  to  extend  transversely  across 
the  neck  at  the  level  of  the  hyoid  bone  from  the  apex  of  the 


.11.       \    - -- — _-      ^ 

l<'n;.  41. — A  Cxstic  Tumour  of  the  Tliyi-i>iil.  iic-i-iiii,\  iiii; 
an  nuusually  high,  position  in  the  neck.  (Seen 
at  St.  B:'ortliolomew's  Hospital.) 


SYMPTOMS   AND   DIAGNOSIS. 


85 


enlarged  left  lobe  to  a  point  beyond  the   middle  line  of  the 
neck. 

In  1892  there  came  under  my  notice  another  patient  of 
Mr.  Butlin's,  a  young  woman  who  had  a  movable  tumour  as 
large  as  a  hazel  nut  situated  just  below  the  tip  of  the  right  great 
corner  of  the  hyoid 
bone ;  after  removal 
it  was  found  to  consist 
entirely  of  thyroid 
tissue. 

In  the  very  rare 
cases  in  which  tumours 
of  thyroidal  origin 
exist  actually  within 
the  larynx  it  may  be 
impossible  to  make  a 
correct  diagnosis. 

The  position  of  a 
thyroid  swelling  with 
regard  to  the  larynx 
and  trachea  has  al- 
ready been  discussed. 
It  remains  for  us  to 
consider  its  position 
with  regard  to  (a)  The 
muscles  of  the  neck  ; 
(b)  The  great  vessels 
of  the  neck ;  (c)  The 
sternum. 

(a)  Position  with  Regard  to  Muscles. — The  position  of  the 
sterno-mastoid  first  demands  our  notice.  This  muscle,  if  the 
tumour  be  sufficiently  large,  is  almost  always  displaced  outwards 
and  forwards.  The  tumour  usually  lies  to  its  inner  side  and  comes 
forwards  more  or  less  between  the  muscles  of  the  two  sides.  If 
bilateral  it  displaces  both  sterno-mastoids. 

Now  a  large  number  of  tumours  of  the  neck,  especially  those 
of  lymphatic  glands  which  at  first  sight  may  closely  resemble 
tumours  of  the  thyroid  gland,  differ  from  the  latter  in  that  they 


Fig.  42. — All  ryj  I  Swiss  ^Vum,•.ll  with  :i  iiromiucnt  Cyst'  ' 
Goitre  of  sm  vll  size  The  tumour  hail  existed  for  many 
yc:irs  but  hml  c.inseJ  no  dyspnoea.  (Seen  at  Fiilo  ivj, 
Swltzerl.'.ud,  in  1886.) 


86 


THE   THYROID   GLAND. 


o   2 


B.  < 


g  a 


^    8 


.if  >> 


O  o 

<l  g 

•fH  -IJ 

"«*  § 

O  2 


^   »  ffi 


SYMPTOMS   AND   DIAGNOSIS.  87. 

displace  the  sterno- mastoid  to  the  inner  side  and  consequently 
project  into  the  posterior  triangle  of  the  neck. 

At  one  time  I  was  inclined  to  attach  more  importance 
to  this  position  of  the  sterno-mastoid  in  the  diagnosis  of 
thyroid  tumour  than  I  do  now,  since  I  have  lately  met  with 
cases  in  which  the  greater  part  of  the  tumour  (undoubtedly 
thyroid)  lay  to  the  outer  and  not  to  the  inner  side  of  the 
muscle. 

I  have  recently  removed  the  right  lobe  of  a  thyroid  gland 
through  an  incision  made  wholly  in  the  posterior  triangle  of 
the  neck,  so  prominent  was  the  swelling  in  this  region  {see 
Appendix,  Case  102). 

Sometimes  the  sterno-mastoid  is  so  much  expanded  and 
thinned  that  it  is  difficult  to  determine  its  exact  position. 

The  infra-hyoid  muscles  are  spread  out  over  the  front  of  the 
tumour,  but  their  exact  position  is  not  easily  ascertained  and 
they  are  of  little  value  for  diagnostic  purposes.  An  exception, 
however,  must  be  made  for  the  omohyoid,  the  lower  belly  of 
which  may  be  made  very  prominent  in  the  posterior  triangle  of 
the  neck  by  a  tumour  of  the  thyroid  gland.  The  infra-hyoid 
muscles  frequently  lie  in  deep  grooves  upon  the  surface  of  the 
gland  and  may  then  produce  sometimes  a  false  appearance  of 
lobulation  in  the  gland. 

Occasionally  a  thyroid  tumour  comes  forward  between  the 
infra-hyoid  muscles  to  such  an  extent  as  to  lie  almost  wholly  in 
front  of  them. 

Fig.  42  taken  from  a  patient  whom  I  saw  at  Fribourg, 
Switzerland,  shows  an  unusually  prominent  goitre,  most  of 
which  lies  anterior  to  the  plane  of  these  muscles. 

Figs.  43  and  44  from  a  patient  under  my  care  at  the  Royal 
Free  Hospital  show  a  somewhat  similar  condition. 

(6)  Position  with  Regard  to  great  Vessels  of  Neck. — As  a 
thyroid  tumour  originates  on  the  inner  side  of  the  carotid  sheath, 
the  latter  becomes  displaced  outAvards  ;  usually  it  is  also  pushed 
backwards,  so  that  the  carotid  artery  may  be  felt  beating  at  the 
posterior  and  outer  part  of  the  tumour.  This  is  its  usual 
position  when  the  thyroid  swelling  is  of  an  innocent  nature. 
When  however  the  gland  is  the  seat  of  malignant  disease,  the 


88  THE   THYROID    GLAXD. 

artery  is  frequently  displaced  to  a  much  slighter  extent,  being 
simply  surrounded  by  the  tumour. 

The  position  of  the  artery  is  therefore  of  some  value  in  the 
differential  diagnosis  between  innocent  and  malisuant  tumours 
of  the  gland,  but  this  subject  will  be  discussed  more  fully  in  a 
subsequent  chapter. 

The  foUowdng  case  illustrates  the  difficulty  that  some- 
times arises  in  the  differential  diagnosis  between  tumours 
of  thyroidal  and  non-thyroidal  origin  and  shows  the  value 
of  a  careful  observation  of  the  exact  position  of  the  carotid 
artery. 

In  February  1895,  a  man  aged  6l  was  admitted  into  St. 
Bartholomew's  Hospital  under  the  care  of  Mr.  Bowlby,  suffering 
from  a  mass  of  malignant  disease  on  the  side  of  the  neck  in  the 
region  of  the  right  lobe  of  the  thyroid.  It  was  as  large  as  a  man's 
fist ;  the  larynx  and  trachea  were  much  displaced  to  the  left,  and 
there  was  urgent  dyspncea  and  dysphagia.  The  carotid  artery 
could  be  felt  pulsating  in  front  of  the  outer  half  of  the  tumour. 
The  tumour  although  at  first  believed  to  be  probably  of  the  thyroid 
gland  was  proved  on  post-mortem  examination  to  be  a  mass  of 
epithelioma  in  the  lymphatic  glands  of  the  neck,  secondaiy  to  a 
growth  in  the  thoi'acic  portion  of  the  oesophagus.  The  right  lobe 
of  the  thyroid  was  of  normal  size  and  compressed  between  the 
turaou    and  the  larynx  and  trachea. 

In  this  case  the  unusual  position  of  the  carotid  artery  afforded 
almost  the  onlv  clue  to  a  correct  diagnosis. 

In  1893  I  had  the  opportunity  of  seeing  an  almost  exactly 
similar  case,  also  in  St.  Bartholomew's  Hospital.  In  this  case 
the  carotid  artery  lay  between  the  tumour  and  the  trachea,  and 
this,  together  with  the  fact  that  the  trachea  and  larynx  could  be 
moved  apart  from  the  tumoui",  made  it  clear  that  the  latter  was 
not  thyroidal.* 

The  position  of  the  internal  jugular  vein  is  a  point  that  merits 
special  attention  since  it  has  important  bearings  upon  the  opera- 
tion for  removal  of  a  goitre. 

Normally,  as  every  one  knows,  the  internal  jugular  vein  lies 
external  to  and  slightlv  in  front  of,  the  carotid  artery  ;  but  as 

*  Both  speciiueu.-;  are  now  iu  the  iiiu?euui  of  St.  B:irtlioloine\v"s  Ho.spital. 


SYMPTOMS   AND   DIAGNOSIS.  89 

the  artery  becomes  displaced,  this  relation  is  gradually  altered. 
The  arterv  is  pushed  outwards  behind  the  vein,  while  the  latter  is 
carried  forwards  and  is  spread  out  upon  the  side  of  the  tumour, 
or  may  even  lie  upon  the  front  of  it.  In  extreme  cases  the 
artery  and  vein  may  be  separated  from  each  other  by  a  consider- 
able interval,  the  vein  lying  in  front  of  and  nearer  to  the  middle 
line  than  the  artery.  Hence  it  does  not  follow  that  the  pulsation 
of  the  artery  ivill  necessarily  indicate  the  position  of  the  vein. 
A  knowledge  of  this  altered  relation  of  the  vein  and  artery  to 
one  another  is  obviously  of  much  importance  to  the  operator 
who,  unless  he  is  aware  of  it,  is  likely  to  wound  the  vein  in  an 
unexpected  manner,  an  unfortunate  accident  by  no  means  un- 
known in  thyroidectomy. 

Liicke  offers  the  following  explanation  of  this  altered  relation, 
Avhich  seems  to  me  to  be  undoubtedly  correct.  The  veins  which 
pass  from  the  thyroid  plexus  to  the  internal  jugular  vein  exercise 
a  certain  amount  of  traction  upon  it  and  tend  to  prevent  its 
lateral  displacement.  The  common  carotid  artery,  however, 
being  devoid  of  branches  and  thus  having  no  such  connections 
with  the  tumour,  is  free  to  move  outwards,  and  accordingly  does 
so  when  pressed  upon  by  the  growth. 

The  superior  thyroid  arteries  can  frequently  be  felt  pul- 
sating at  the  upper  and  inner  border  of  the  thyroid  tumour, 
and  may  occasionally  be  of  some  slight  help  towards  a  diag- 
nosis. 

if)  Position  with  regard  to  Sternum  and  Clavicle. — 
The  relation  of  the  tumour  to  the  sternum  is  one  of  great 
importance  with  regard  to  prognosis  in  cases  of  thyroid 
tumour,  although  from  a  diagnostic  point  of  view  it  is  of  less 
interest. 

A  thyroid  tumour,  unless  quite  small,  generally  extends 
as  low  down  as  the  upper  border  of  this  bone.  It  fre- 
quently descends  below  this  level.  Rarely  does  the  tumour 
descend  in  front  of  the  sternum,  except  in  the  case  of  very 
large  goitres.  Behind  the  sternum,  however,  prolongations 
often  extend  downwards  for  a  considerable  distance  into 
the  mediastinum.  McWhinnie,  in  his  lectures  upon  broncho- 
cele,  figures  a  case  of  this  kind  in  which  the  goitrous  prolonga- 


9.0 


THE   THYROID   GLAND. 


tion    extended    downwards    as   far   as  the  bifurcation    of  the 
trachea,* 


Fig.  45. — The  Eight  Half  of  a  maiuly  Pareuchymatoiis  Goitre  removed  by 
Extirpation  ou  acaoiiut  of  severe  Dyspuoja.  The  inferior  horu 
extended  deeply  into  the  thorax.  The  indentation  produced  hy  the 
fir.st  rib  is  very  marked.  From  a  woman  aged  44  (Case  20f;.  (Royal 
Free  Hosp.  Mus.  Xo.  xxii.  58.)     (Sliyhtly  reduced.) 


*  Lancet,  1861,  vol.  ii.  p.  30. 

t  This  case  was  published  in  the  Brit.  Mrd.  Jouvn.  for  July  7.  1900. 
Owing  to  foreshortening-  the  inferior  horu  appears  in  the  figure  to  be  a  little 
wider  than  it  should  be. 


SYMPTOMS   AND    DIAGNOSIS.  91 

In  a  case  of  my  own  in  which  I  removed  a  substernal  goitre 
that  was  causing  serious  pressure  upon  the  trachea  I  found  that 
the  lowest  part  of  the  goitre  was  no  less  than  Qh  inches  below 
the  lower  border  of  the  isthmus  ;  in  other  words  between  two 
and  three  inches  of  the  tumour  lay  behind  the  sternum,  {See 
Fig.  45.) 

In  some  cases  the  goitre  lies  almost  entirely  below  the  level 
of  the  upper  border  of  the  sternum. 

In  December  1892,  I  assisted  Mr.  Anthony  Bowlby  at  an 
operation  upon  a  large  cystic  goitre  which  lay  almost  entirely 
behind  the  sternum.  The  upper  border  of  the  cyst  was  about 
one  inch  above  the  sternum,  the  lower  border  was  in  contact 
with  the  arch  of  the  aorta,  which  could  be  plainly  seen  and  felt 
at  the  bottom  of  the  wound. 

In  1893  I  removed  a  large,  partly  solid  and  partly  cystic, 
goitrous  tumour,  measuring  2J  inches  in  diameter,  from  the 
thorax  of  a  man  aged  fifty-three.  During  ordinary  respiration 
the  tumour  lay  so  deeply  in  the  thorax  that  there  was  no 
perceptible  swelHng  in  the  neck,  and  the  top  of  the  tumour 
could  only  just  be  felt  on  palpation.  This  goitre  had  caused 
most  severe  dyspnoea.* 

A  case  in  which  the  goitre  descended  as  low  as  the  ninth 
dorsal  vertebra  has  also  been  recorded. f 

To  tumours  such  as  these  the  name  of  "  substernal  goitre "" 
{goitre  plongeant)  is  often  applied. ;j:  They  form  a  class  of 
exceedingly  dangerous  tumours  often  very  difficult  to  diagnose. 
Naturally  they  may  easily  be  confused'jwith  various  other  medias- 
tinal swellings  such  as  enlarged  lymphatic  glands,  thoracic 
aneurism,  or  malignant  growth. 

Wolfler  I  has  recorded  a  very  singular  case  in  which  a  goitre 
changed  its  position  from  time  to  time,  lying  sometimes  in  the 

*  This  case  is  described  more  fully  on  pp.  105,  106.  The  tumour  is  now 
in  the  Eoyal  Free  Hosp.  Mus.  No.  xxii.  59. 

t  Kretschy,  \Vte7t,.  Med.  Wochemchi-.,  1877,  No.  1, quoted  by  Liebrecht,  "  De 
I'excision  du  goitre,  &c.,"  p.  146. 

X  Another  case  of  this  nature  was  shown  to  me  in  1886  by  Dr.  Kottmann  in 
his  wards  at  the  hospital  at  Soleure,  Switzerland.  The  goitre  lay  almost  entirely 
within  the  thorax  and  produced  most  violent  dyspnoea. 

§  "  Ueber  den  wanderuden  Kropf,"  Wien  lilin.  Wochetischr. ,  1889,  ii.  371- 
373. 


9-^  THE   THYROID   GLAND. 

neck,  sometimes  in  the  thorax.  ^Vhen  in  the  former  situation, 
it  formed  an  obvious  prominent  swelling  as  large  as  a  hen's  egg 
and  gave  rise  to  no  respiratory  trouble.  When  it  slipped  down 
into  its  thoracic  position  it  could  no  longer  be  seen  or  felt,  but  it 
then  caused  very  severe  respiratory  and  circulatory  trouble  by 
pressing  upon  the  trachea  and  upon  the  innominate  vein.  The 
goitre  Mas  discovered  during  the  course  of  an  exploratory 
operation  which  was  undertaken  for  the  relief  of  the  dyspnoea 
that  was  threatening  the  patient's  life.  A  distinct  cavity  lined 
by  a  connective-tissue  capsule  was  found  behind  the  inner  end  of 
the  clavicle,  and  here  it  was  that  the  tumour  lav  when  not  in 
the  neck.  Another  curious  feature  of  the  case  was  that  when 
in  its  thoracic  position  the  goitre  became  nearly  twice  as  large 
as  it  was  when  in  the  neck.  This  was  due,  according  to  AVolfler\s 
explanation,  to  the  pressure  exerted  upon  the  veins  returning 
from  the  goitre.* 

Pulsation. — This  is  so  commonly  described  as  existing  in  a 
thyroid  tumour  that  it  deserves  brief  mention.  Pulsation  is 
often  due  simply  to  the  close  proximity  of  the  carotid  artery 
Avhich  communicates  its  pulsation  to  the  adjacent  mass.  Fre- 
quently the  pulsation  felt  is.not  that  of  the  carotid  but  of  the 
superior  thyroid  artery  which  runs  along  the  anterior  and  inner 
border  of  the  lateral  lobe  of  the  thyroid ;  large  arterial  branches 
sometimes  run  over  the  surface  of  large  goitres  and  may  be 
easily  felt  and  even  seen  in  this  situation.  Occasionally  the 
whole  tumour  appears  to  have  an  inherent  pulsation  and  this  is 
especially  the  case  with  the  goitre  of  Graves's  disease.  Inherent 
pulsation  was  very  marked  in  the  case  of  the  large  malignant 
goitre  depicted  in  Fig.  82.  In  this  case  the  pulsation  was 
probably  due  to  large  vessels  ramifying  within  the  unusually 
vascular  growth. 

The  pulsation  of  a  thyroid  tumour  has,  not  unnaturally,  led 
in  many  cases  to  an  erroneous  diagnosis  of  aneurism.  Numerous 
cases  of  the  kind  have  been  recorded.  One  of  the  most  interesting 
is  that  of  Xelaton's  quoted  by  Mc^Vhinnie.■f  On  the  right  side 
of  the  neck  just  above  the  clavicle  and  behind  the  sterno-mastoid 

*  Au  almos^t  exactly  similar  case  of  my  own  is  described  on  pp.  105,  106. 
f  Lancet.  1862,  vol.  i.  p.  64. 


SYMPTOMS   AND    DIAGNOSIS.  93 

was  a  firm  tumour  which  pulsated  forcibly.  The  common  carotid 
arterv  could  be  traced  over  it.  It  was  pronounced  to  be  an 
aneurism  of  the  aorta.  Post-mortem  examination  showed  the 
presence  of  a  goitre,  not  of  an  aneurism.  In  1887  Dr.  Clave 
Shaw  showed  me  at  Banstead  Lunatic  Asylum  a  middle-aged 
woman  who  had  an  oval  swelling  as  large  as  a  hen''s  e^g^  in  the 
situation  of  the  right  lobe  of  the  thyroid  gland.  It  pulsated 
strongly.  It  moved  with  the  larynx  during;  deo-lutition  and  was 
clearly  an  innocent  goitre,  probably  cystic.  Nevertheless  this 
had  been  mistaken  for  a  carotid  aneurism  by  another  doctor 
who  had  previously  seen  the  case,  and  it  was  at  first  difficult  to 
persuade  him  that  it  was  only  a  goitre,  and  that  the  pulsation 
was  communicated  from  the  carotid. 

The  converse  may  be  illustrated  by  a  case  I  saw  with  Dr.  Gray 
at  the  Islington  Infirmary  in  1886.  A  middle-aged  woman  had 
a  pulsating,  elastic,  oval,  deep-seated  swelling  at  the  root  of  the 
neck  just  above  the  episternal  notch.  In  one  lobe  of  the  thyroid 
o;land  was  a  small  indurated  mass,  evidently  the  remains  of  an 
old  shrunken  goitre.  The  question  arose  whether  the  pulsating 
swellino;  was  derived  from  the  thyroid  gland  or  whether  it  ^\'as 
an  aortic  aneurism.  Careful  examination  however  showed  that 
the  thyroid  swelling  moved  independently  of  the  pulsating  mass, 
and  it  was  decided  that  the  latter  was  an  aneurism.  There  were 
besides  other  symptoms  of  thoracic  aneurism. 

Dr.  Carver  of  Addenbrooke's  Hospital,  Cambridge,  has  kindly 
communicated  to  me  through  Mr.  A.  G.  Francis  the  particulars 
of  the  case  of  an  elderly  man  who  had  a  malignant  cyst  of  the 
thyroid  gland.  He  had  been  sent  to  the  hospital  as  a  case  of 
carotid  aneurism.  Pulsation  was  marked  but  there  was  no 
bruit. 

In  Nov.  1895,  I  saw  with  Dr.  W.  B.  Fergusson  at  Painswick, 

Gloucestershire,  Mrs. ,  aged  fifty-nine,  who  had  noticed  a 

month  previously  a  pulsating  swelling  at  the  root  of  the  neck 
just  above  the  sternum.  The  right  carotid  artery  was  displaced 
forwards  and  could  be  moved  upon  the  tumour.  There  was  a 
patch  of  dulness  about  two  inches  in  diameter  just  below  the 
inner  end  of  the  clavicle.  The  right  sympathetic  nerve  was 
partially  paralysed.     The  thyroid  gland  appeared  to  be  slightly 


94 


THE   THYROID    GLAND. 


•5  a 

'A    o 


SYMPTOMS   AND   DIAGNOSIS.  95 

enlarged  and  had  no  obvious  connection  with  the  tumour.  The 
radial  pulses  were  equal.  There  was  no  bruit.  ^\'hen  the 
patient  strained,  the  swelling  at  the  root  of  the  neck  became 
more  prominent.  There  was  little  or  no  dvspncea.  In  this 
case  I  was  uncertain  whether  the  patient  ^\"as  sufFerino-  from  an 
aortic  or  innominate  aneurism  or  a  substernal  o-oitre  transmittino- 
pulsation  from  the  aorta.  Three  years  later  (Sept.  1898)  the 
patient  was  still  in  good  health  and  the  tumour  had  not  increased 
in  size  :  there  was  no  doubt  that  the  case  was  one  of  substernal 
goitre  and  not  aneurism. 

Dalrvmple  *  and  Raynaud  t  have  also  recorded  similar  cases 
of  ffoitre  simulating;  anem"ism. 

It  might  be  supposed  that  the  presence  of  a  bruit  would  serve 
to  distinguish  an  aneurism  from  a  thyroid  tumour.  This  would 
however  be  a  most  fallacious  supposition,  since  a  well-marked 
bruit  is  often  heard  in  a  case  of  simple  goitre.  It  was  partly 
owing  to  the  presence  of  a  bruit  that  Nekton  was  led  to  the 
erroneous  diagnosis  above  mentioned. 

In  1886  I  saw  with  Dr.  Raglan  Thomas  at  Llanellvan  elderly 
woman  with  a  large  right-sided  oval  goitre  which  had  existed 
for  many  years.  An  exceedingly  loud  and  harsh  murmur  was 
audible  all  over  the  right  side  of  the  tumour.  There  was  no : 
cardiac  bruit.  Figs.  46  and  -17  represent  a  woman  whom  I  saw 
at  the  village  of  Sevington  St.3Iarv,  in  Somersetshire.  She  had 
a  very  large  goitre,  over  parts  of  which  a  loud  harsh  murmur 
could  be  heard. 

In  the  case  of  another  woman,  under  the  care  of  Sir  Thomas 
Smith  in  St.  Bartholomew's  Hospital,  a  very  loud  murmur  was 
audible  along  the  inner  border  of  the  left  lobe  of  the  goitre.  In 
this  case  over  the  same  region  was  a  very  well  marked  thrill. 
In  all  these  cases,  the  murmur  was  equally  audible  whether 
pressure  was  made  upon  the  tumour  bv  the  stethoscope  or 
not. 

In  manv  cases  however  the  murmur  is  simplv  factitious,  pro- 
duced by  the  pressure  of  the  stethoscope,  but  it  is  not  necessary 
to  quote  anv  examples  of  this  common  condition. 

*  Jovvn.  of  2Iorh.  Anat.,  Lond.  1828,  i.  43-47. 
t  SriU.  Soc.  Anat.  de  Paris,  18.59,  sxxir.  348-350. 


9fi 


THE   THYROID    GLAND. 


Consistence. — This  may  be  of  any  deoroe  between  extreme 
softness  and  stony  hardness.     Examples  of  the  foriner  may  be 

seen   in  many  cases   of  soft 
,-rj=r!=^^  '"'.if^^^S^^  parenchymatous    goiti'e,    i)i 

some  adenomata  and  in  par- 
tially filled  thin-walled  cysts. 
Some  parenchymatous  goi- 
tres containing  numerous 
small  tense  cysts  are  ex- 
tremely hard.  So  are  the 
rare  fibrous  goitres.  The 
hardest  goitres  are  naturally 
those  which  have  become 
calcified.  Most  museums 
contain  specimens  illustrat- 
ino-  this.  One  of  the  best 
that  have  come  under  my 
notice  may  be  seen  in  the 
inuseum  of  the  Sussex 
County  Hospital  at  Brigh- 
ton. A  goitre  as  large  as 
a  man's  fist  has  become 
almost  entirelv  calcified. 
There  are  also  two  beautiful 
specimens  in  the  Pathological  IVIuseuni  at  Prague.* 

Pressure  Effects.  —  An  enlarged  thyroid  gland  causes 
pressure  upon  various  surrounding  structures.  Many  of  the 
svmptoms  thus  produced  are  of  the  utmost  importance. 

Pressure  on  Veins. — This  is  very  common.  The  veins  chiefly 
affected  are  those  which  bring  blood  from  the  head  and  neck, 
namelv  the  internal,  external  and  anterior  jugular.  The 
innominate  and  even  subclavian  veins  may  be  compressed  by  a 
goitre  deeplv  seated  at  the  root  of  the  neck.  The  pressure  on 
the  jugular  veins  causes  distension  and  dilatation  of  them  and 
frequentlv    they    become    very    prominent. 


Y\G.  48. — A  Mass  of  (  iikMrcoiis  ^laterial  re- 
moved, after  maceration,  from  an  old  Goitre- 
(St.  Bart.  Hosp.  Mus.  Xo.  2317.J   (Eularaed  #. ) 


Fisi-s.    rS9    and    56 


*  For  other  examples  of  calcification  see  Univ.  Coll.  Mus.  Xo.  1361  ;  St. 
Bart.  Hosp.  Mus.  Xos.  2316  and  2317:  Guy's  Hosp.  Mus.  121,  122,  128: 
King's  Coll.  Mus.  280. 


SYMPTOMS   AND    DIAGNOSIS.  97 

show  examples  of  the  venous  distension  caused  by  goitres. 
The  obstruction  offered  to  the  venous  circulation  is  said  by  some 
to  cause  buzzing  in  the  head,  deafness,  vertigo  and  various 
other  symptoms  :  the  accuracy  of  these  statements  is,  however, 
questionable.  (Edema  of  the  face  and  even  of  the  arm  are 
said  to  be  produced  occasionally  by  goitre  but  I  have  myself 
never  seen  an  example  of  either  and  should  doubt  whether 
they  ever  occur  except  in  cases  of  malignant  or  inflamed 
goitre. 

Pressure  on  Nerves. — An  innocent  goitre,  even  though  of 
large  size,  rarelv  causes  much  pressure  upon  nerves.  In  cases  of 
malignant  disease,  however,  pressure  upon,  or  involvement  of 
important  nerves,  often  causes  early  and  well-marked  symptoms 
of  the  affection.     {See  p.  208.) 

The  chief  nerves  pressed  upon  by  an  enlarged  thyroid  gland 
are  («)  the  recuiTent  laryngeal,  (5)  the  sympathetic,  (c)  the 
vagus,  and  {d)  occasionally  the  nerves  of  the  cervical  and  brachial 
plexuses. 

(a)  Recurrent  Laryngeal  Nerve. — Occasionally,  it  is  found 
that  the  recurrent  nerve  is  spread  out  upon  the  posterior  surface 
of  a  croitre.  When  this  is  the  case,  more  or  less  interference 
with  its  function  may  take  place.  More  often,  however,  the 
nerve  is  pushed  inwards  and  is  not  stretched  by  the  goitre.  It 
is  important  to  bear  in  mind  that  the  dyspnoea  caused  by 
innocent  goitre  is,  in  the  vasb  majority  of  cases,  produced  by 
direct  pressure  upon  the  trachea,  and  not,  as  is  sometimes 
alleged,  bv  irritation  of  the  recurrent  nerves  causing  spasm  of 
the  glottis. 

In  cases  of  malignant  disease,  the  nerve,  as  might  be  expected, 
is  frequentlv  found  involved  in  the  tumour. 

Complete  paralysis  of  a  vocal  cord,  caused  by  a  thyroid 
tumour,  should  always  be  looked  upon  with  some  suspicion,  as 
affording  a  presumption  of  the  malignant  nature  of  the  latter. 
Too  much  importance  must  not,  hoAvever,  be  attached  to  this 
symptom  alone.  I  have  seen  several  cases  of  complete  para- 
lysis of  one  vocal  cord  caused  by  a  goitre  undoubtedly  not 
malignant. 

Thus,  Dr.    Ravner  Batten    sent   to    me    at  the    Royal   Free 


98 


THE   THYROID    GLAND. 


a    tp 


O  •- 

g  ^ 

o  „ 

03  a 

OS  i 

Ah  ~ 


SYMPTOMS   AND   DIAGNOSIS.  99 

Hospital,  a  girl  who  had  had,  for  several  years,  a  right-sided 
bronchocele  as  large  as  an  orange.  The  vocal  cord  on  the 
corresponding  side  was  completely  paralysed.  Nevertheless, 
from  the  clinical  history  of  the  case,  it  was  evident  that  the 
goitre  was  not  malignant. 

In  1888  I  saw,  at  St.  Bartholomew's  Hospital,  a  young 
man  under  the  care  of  ]\Ir.  Howard  Marsh.  A  moderately 
large  unilateral  goitre  had  caused  complete  paralysis  of  the 
left  vocal  cord.  This  symptom,  together  with  the  compara- 
tive fixity  of  the  tumour,  and  its  rather  rapid  groAvth  raised 
a  suspicion  of  malignancy.  An  operation  for  removal  of 
the  tumour  showed  it,  however,  to  be  an  innocent  cystic 
adenoma. 

Figs.  49,  50,  51,  show  a  woman  from  whom  I  removed  a 
goitre  of  moderate  size,  on  account  of  dyspnoea.  Before  the 
operation  one  vocal  cord  was  seen  to  be  completely  paralysed. 
The  goitre  was  nevertheless  perfectly  innocent. 

(b)  Cervical  Sympathetic  Nerve. — This,  also,  is  affected 
rarely  by  innocent  growths  of  the  thyroid,  more  frequently  by 
malignant  disease. 

The  following  is  an  example  of  an  innocent  goitre  causing 
contraction  of  the  pupil  by  pressure  upon  the  sympathetic 
nerve : 

Miss  Alice    E ,  aged  Si,  consulted   me   in  October  1887,  on 

account  of  a  small  goitre  which  she  had  had  for  at  least  ten  years. 
In  the  left  lobe  of  the  gland  was  a  rounded  cystic  adenoma  about 
as  large  as  a  hen's  egg.  It  was  freely  movable  and  caused  little 
or  no  inconvenience.  The  pupil  of  the  left  eye  was  little  more 
than  half  as  large  as  that  of  the  right  side.  The  palpebral  fissure, 
too,  was  distinctly  narrower  on  the  left  side.  The  patient  informed 
me  that  she  had  noticed  that  during  menstruation,  when  the  goitre 
became  larger,  the  left  pupil  became  still  more  contracted.  I  was 
unable  to  detect  any  alteration  in  the  sweating  or  vascularity  of 
the  corresponding  side  of  the  head.  This  lady  was  seen  again 
in  August  of  the  following  year.  The  goitre  was  unaltered 
and  the  difference  between  the  two  pupils  was  just  as  marked 
as  before.  At  no  time  had  there  been  any  disease  of  the  eye  or 
anything  else,  except  the  goitre,  to  cause  the  contraction  of  the 
pupil. 


100  THE   THYROID    GLAND. 

An  excellent  example  of  the  involvement  of  the  sympathetic 
nerve  by  a  malignant  growth  oi  the  thvroid  gland  mav  be  seen  in 
Fig.  81  (p.  208).  I  saw-  this  man  with  Mr.  Howard  ^larsh,  at  St. 
Bartholomew's  Ho.spital,  in  the  autumn  of  1887.  A  goitre  of  many 
vears  duration  had,  within  the  last  few  months,  grown  consider- 
ably, and  caused  the  contraction  of  the  right  pupil  and  palpebral 


I'lG.  51. — The  sime  (Fiy-s.  49  aud  50)  showing:  the  scar  a  week  after  operation. 
(.S'ec  Appendix.  Case  112,  p.  352.) 

fissure  shown  i)i  the  photograph.  Partly  on  this,  and  partly  on 
other  grounds,  \vi.>  considered  the  disease  to  be  malignant,  and 
ad^■ised  that  no  operation  should  be  performed.  The  diagnosis 
was  subsequently  verified,*  the  patient  dying  in  the  course  of 
the  following  year. 

*  The  subsetiuent  history  of  thi.s  patient  has  been  published  by  Mr.  Sydney 
Jones  and  Mr.  Battle  in  St.  Tlunnati's  IIo-<p'dal  Bej)ort.~;,  1888  -9,  a"o1.  xviii. 
p.  233.     See  also  p.  213. 


SYMPTOMS   AND    DIAGNOSIS.  101 

It  Mas  formerly  believed  by  some  that  many  of  the  symptoms 
of  Graves''s  disease  were  attributable  to  an  irritation  of  the 
cervical,  sympathetic,  and  vagus  nerves  caused  bv  pressure  of 
the  goitre  upon  them.  I  allude  to  this  theory  only  to  say  that 
evidence  in  support  of  it  is  wholly  absent. 

(c)  Pressure  upon  the  nerves  of  the  cervical  and  brachial 
plexus  is  occasionally  produced  by  innocent  goitres,  and  may 
cause  numbness  and  tingling  or  even  severe  pain  in  the  side  of 
the  head  and  neck,  or  down  the  arm.  In  cases  of  malignant  and 
inflamed  goitres,  these  symptoms  are  common.  In  my  lectures  * 
on  goitre,  delivered  before  the  Royal  College  of  Surgeons 
in  1891,  Avas  recorded  the  case  of  a  man,  aged  64,  from 
whom  I  enucleated  a  large  cyst  of  the  left  lobe.  This  had 
caused,  for  some  months,  severe  pain  in  the  left  side  of  the  head 
and  neck,  and  I  was  inclined,  at  first,  to  suspect  malignancy. 
The  tumour  proved,  however,  to  be  quite  innocent,  and  after 
recovery  from  the  operation,  the  patient  remained  quite  free 
from  pain. 

Pressure  upon  Larynx  and  Trachea. — The  larvnx  is  fre- 
quently displaced  to  one  or  other  side,  and  is  sometimes  slightly 
indented  by  the  long-continued  pressure  of  a  goitre. 

A  good  example  of  deformity  of  the  larynx  caused  bv 
the  pi'essure  of  a  goitre  may  be  seen  in  Guy's  Hospital 
Museum. j- 

It  is  upon  the  trachea  more  than  any  other  structure  that  an 
enlarged  thyroid  gland  is  liable  to  press,  and  thus  produce 
injurious  effects.  This  is  scarcelv  surprising  when  we  reflect 
how  intimately  the  trachea  is  connected  with,  and  embraced  by 
the  thyroid  gland.  Any  enlargement  of  the  latter  can,  there- 
fore, hardly  fail  to  produce  some  pressure  upon  it.  Only  too 
commonly  is  this  pressure  the  cause  of  serious  and  even  fatal 
trouble  to  the  patient. 

The  pressure  which  an  enlarged  thyroid  gland  exerts 
upon  the  trachea  may  lead  to  :  (i)  Displacement ;  (ii)  Com- 
pression. 

(i)  Displacement. — By  far  the  most   common  displacement 
caused  by  the  pressure  of  a  goitre  is  a  lateral  one,  the  trachea 
*  B)-if.  Med.  Journ.,  June  27,  isyi.  j  ^'p-  l'^^* 


10^  THE   THYROID    GLAND. 

being  pushed  over  to  one  or  other  side  bv  tlie  enlargement  of  the 
opposite  lobe  of  the  gland. 

This  displacement  is  always  accompanied  bv  a  certain  amount 
of  curving  of  the  trachea  upon  itself,  and  frequently  by  some 
twisting  of  the  trachea  upon  its  long  axis. 

In  very  rare  cases  the  trachea  is  displaced  directlv  or  obliquely 
forwards. 

(ii)  Compression. — The  trachea  being  composed  of  incomplete 
rings  of  cartilage  which  are  open  posteriorlv,  readilv  admits  of 
compression  and  narrowing  of  its  lumen.  In  proportion  as  the 
trachea  is  diminished  in  calibre  so  does  the  patient's  breathing 
become  laboured,  and  in  fact  we  find  that  difKcultv  in  breathing 
is  one  of  the  most  common  symptoms  of  goitre.  The  brassy 
nature  of  the  cough  caused  by  the  pressure  of  the  tumour  is  well 
known  to  be  characteristic  of  compression  of  trachea  or  bronchus 
and  may  generally  be  readily  distinguished  from  that  which  is 
due  to  laryngeal  obstruction.* 

That  the  dyspnoea  caused  by  goitre  is  due,  in  most  instances, 
to  direct  pressure  upon  the  trachea  itself,  and  not  to  pressure 
upon  the  recurrent  laryngeal  nerves,  is  shown  by  the  rarity  with 
which  dysphonia  occurs.  Dyspnoea  is  one  of  the  commonest 
accompaniments  of  a  thyroid  enlargement.  Dysphonia  is  dis- 
tinctly rare. 

The  whole  subject  of  displacement  and  compression  of  the 
trachea  will  be  discussed  more  fully  in  the  next  chapter,  which 
deals  with  the  dyspnoea  produced  by  enlargement  of  the  thyroid 
gland. 

It  will  be  sufficient  to  mention  here  briefly  that  the  compres- 
sion of  the  trachea  is  almost  invariably  lateral  and  not  antero- 
posterior. This  has  a  very  important  bearing  upon  the  treat- 
ment of  the  dyspnoea  produced  by  goitre. 

Pressure  upon  CEsophagu.s  and  Larynx. — The  oesophagus 
lying  behind  the  trachea  is  much  less  often  compressed  than  is 
the  latter.  It  is  not  uncommon,  however,  for  one  or  other  lobe 
of  the  giand,  or  even  both  lobes,  to  extend  behind  the  trachea 

*  Any  one  who  wishes  to  produce  an  exact  imitation  of  this  brassy  cough 
may  easil}-  do  so  in  his  own  person  by  making  tirm  pressure  with  his  thumb 
upon  the  trachea  just  above  the  sternum,  and  then  coughing. 


SYMPTOMS   AND   DIAGNOSIS.  10 

and  displace  the  oesophagus  to  one  side  or  to  compress  it  on 
both  sides. 

In  the  Museum  of  King's  College  Hospital  *  is  a  well-marked 
example  of  deviation  and  compression  of  the  oesophagus  from  a 
prolongation  of  the  left  lobe  of  a  goitre  which  extends  behind 
the  trachea. 

In  the  Pathological  Museum  of  Berne  is  an  excellent  collection 
of  no  less  than  four  well-marked  examples  of  goitre  causing 
pressure  upon  the  oesophagus. 

A  case  which  came  under  my  notice  several  years  ago  was  that 
of  a  woman  who  was  admitted  into  one  of  the  London  hospitals 
and  treated  for  a  time  by  bougies  for  oesophageal  stricture  sup- 
posed to  be  malignant.  There  was,  however,  no  true  stricture, 
the  difficulty  in  swallowing  being  caused  simply  by  the  pressure 
of  a  small  unilateral  goitre  which  had  at  first  escaped  observa- 
tion. 

Kaufman,"f  in  his  article  on  i-etro-pharyngo-oesophageal  goitre, 
has  collected  several  cases,  one  of  them  under  his  own  care,  in 
which  a  distinct  prolongation  of  the  gland  extended  behind  the 
pharynx  and  oesophagus  and  caused  much  difficulty  in  swallow- 
ing. In  one  of  these  the  dysphagia  was  so  great  that  oesopha- 
gotomy  was  performed,  unfortunately  with  a  fatal  result. 
Another  case  has  been  recorded  in  which  death  by  starvation 
actually  occurred  from  the  pressure  of  a  goitre  upon  the 
oesophagus.^ 

In  several  of  my  own  operations  upon  parenchymatous  goitres 
I  have  noticed  the  existence  of  small  prolongations  of  the 
growth  behind  the  pharynx  and  oesophagus. 

In  February  1895  I  saw  a  young  woman  aged  thirty-six  who 
was  admitted  into  St.  Bartholomew's  Hospital  under  the  care  of 
Sir  Thomas  Smith,  complaining  of  dysphagia.  The  passage  of 
a  full-sized  oesophageal  bougie  showed  that  no  real  stricture 
existed.     A  small  deep-seated  goitre  involving  the  isthmus  and 

*  No.  277. 

t  Eeported  by  Lotzbeck  from  Prof.  Bruns'  wards  "  Chirurg.  Mitth.  aus  der 
Klinik  von  Prof.  v.  Bruns  in  Tubingen,"  in  Deutscli.  Klin.  JaJirg.,  1859,  vol.  xi. 
p.  59. 

X  p.  Koch,  "Ann.  d.  mal.  d'oreille  et  du  larynx,"  Paris,  1881,  vii.  p.  88. 


104  THE   THYROID    GLAND. 

left  lobe  of  the  thyroid  gland,  and  of  the  existence  of  which  the 
patient  w  as  quite  ignorant,  appeared  to  be  the  main  cause  of  the 
dysphagia. 

It  is  by  no  means  uncommon  to  see  a  marked  bulging  inwards 
of  the  pharyngeal  wall  caused  by  the  pressure  of  a  goitre. 
Sometimes,  when  the  goitre  is  especially  well  developed 
posteriorly,  this  bulging  may  be  very  marked  even  if  the 
goitre  present  but  little  external  swelling. 


CHAPTER   VII. 

THE   DYSPNOEA   CAUSED    BY   GOITRE. 

Frequency  and  importance — Pressui-e  upon  trachea — Lateral  com- 
pression— Scabbard -shaped  trachea — Effect  on  trachea  of  bilateral 
goitre,  unilateral,  median  —  Softening  of  tracheal  wall  —  Pressm-e 
upon  recurrent  nerves — Direct  extension  to  trachea — Eupture  of  cyst 
or  abscess — QEdema  of  glottis — Swelling  of  tracheal  mucous  membrane 
— Varieties  of  goitre  most  likely  to  cause  dyspnoea  ;  relation  to  age  and 
sex — Danger  of  bilateral  goitre  of  puberty  and  of  deeply  seated  goitres 
— Table  of  cases  of  goitre  causing  death  by  suffocatiou. 

Of  the  various  symptoms  which  may  be  produced  by  an  enlarge- 
ment of  the  thyroid  gland,  dyspnoea  is,  undoubtedly,  by  far  the 
most  important. 

In  95  out  of  the  126  cases  in  which  I  have  myself  had  to 
remove  a  goitre  the  chief  reason  for  the  operation  was  dyspnoea. 

In  16  of  the  other  cases,  some  dyspnoea  was  also  present, 
although  it  Avas  not  the  main  reason  for  the  operation. 

Frequently,  dyspnoea  is  the  only  inconvenience  of  which  a 
goitrous  patient  complains  and  for  which  he  seeks  advice. 
Often  it  is  present  to  such  an  extent  that  a  constant  dread 
of  impending  suffocation  hangs  over  the  unfortunate  sufferer, 
and  prevents  him  from  following  any  regular  occupation. 

Only  too  often  is  death  itself  the  result  of  the  gradually  or 
suddenly  increasing  dyspncjea.  {See  table  of  cases  at  the  end  of 
this  chapter.) 

It  is  not  verv  uncommon  for  a  patient  to  seek  advice  with 
regard  to  dvspnoea,  the  cause  of  which  is  unknown  until  an 
examination  of  the  neck  reveals  the  presence  of  a  goitre  which 
had  hitherto  not  been  noticed  by  the  patient. 

The  following  is  a  good  example  : 

Archibald  T ,  aged  53,  was    admitted  in    March    1893   into 

the     Royal     Free     Hospital     under    the     care     of    my    colleague 


106  THE    THYROID    GLAND. 

Dr.  SainsbuiT;,  suffering  from  a  severe  attack  of  Avhat  was  at  first 
supposed  to  be  '^asthma."  The  dyspnoea  was  so  extreme  that  it 
was  thought  that  the  man  was  about  to  die  and  the  propriety  of 
performing  tracheotom}-  was  discussed  by  the  resident  medical 
officers.  The  breathing  improved  somewhat  however  after  a  few 
hours  rest  in  bed.  When  Dr.  Sainsbury  saw  the  patient  a  slight 
fulness  Avas  discovered  at  the  root  of  the  neck  just  above  the 
sternum.  This  was  the  top  of  a  large  substernal  goitre  of  whose 
existence  the  patient  Avas  quite  unaware.  I  subsequently  removed 
the  goitre  by  operation.  The  patient  made  a  good  recovery  and 
was  entirely  freed  from  dyspncea.  Six  years  after  the  operation  he 
was  still  in  excellent  health  and  had  had  no  further  trouble  of  any 
kind. 

Cases  have  come  to  niv  knowledge  in  wliich  dyspnea  has 
been  supposed  to  be  due  to  asthma  or  bronchitis,  and  treated 
accordingly  for  months  or  years,  the  true  cause  lying,  wholly 
unsuspected,  in  an  enlargement  of  the  thyroid. 

Such  mistakes  are  most  likely  to  occur  in  cases  of  small  and 
symmetrica],  or  deep-seated  tumours,  and  these  are  especially 
liable  to  cause  severe  dyspnoea. 

The  following  case  has  been  published  by  Gaucher  :  * 

In  May  18-i2,  a  man  aged  28  was  admitted  to  M.  Husson's  wards 
in  the  Hotel  Dieu.  He  was  quite  unconscious  and  was  breathing 
in  a  laboured  manner.  It  was  known  that  for  a  long  time  he  had 
suffered  from  dyspnoea,  although  it  had  never  before  been  so  bad  as 
to  threaten  life.  It  was  said  also  that  he  had  pain  about  the  region 
of  the  ears.  Some  cerebral  affection  Avas  diagnosed  and  leeches 
were  applied  to  the  mastoid  processes.  No  relief  followed,  the 
patient  became  more  and  more  cyanosed  and  died  on  the  following 
day.  At  the  post  mortem  the  ordinary  signs  of  death  by  suffocation 
Avere  discovered.  The  thyroid  gland  Avas  enlarged  in  all  parts  and 
contained  also  a  few  small  cysts.  Death  was  attributed  to  pressure 
upon  the  trachea. 

The  remainder  of  this  chapter  will  be  devoted  to  a  considera- 
tion of  the  various  modes  in  which  dyspnoea  may  be  caused  by 
diseases  of  the  thyroid  and  to  the  varieties  of  such  diseases 
which  are  most  liable  to  cause  dyspnoea. 

*  "  Asphyxie  par  hypertrophie  de  la  glande  tliyroile,"  Bull.  Huf.  Anitt.  dp 
Purls.  1842,  xvii.  178. 


THE   DYSPXCEA    CAUSED    BY   GOITRE.  107 

There  are  various  ways  in  which  an  enlarged  thyroid  may 
cause  dyspnoea. 

1.  Direct  pressure  upox  the  trachea. — This  is  by  far  the 
most  common  and  important.  • 

Occasionally  other  conditions  have  some  share  in  the  pro- 
duction of  the  dyspnoea,  either  alone  or  more  often  in  combina- 
tion with  the  preceding.     Such  are  : 

2.  Pressure  upon  or  other  irrfpatiox  of  the  recurrent  laryn- 
geal neryes. 

3.  Direct  extexsiox  of  growth  into  the  interior  of  the 
trachea  or  larynx  (yery  rare,  except  in  cases  of  malignant 
disease,  in  which  it  is  common). 

4.  Rupture  of  a  cyst  or  abscess  into  the  air  passages. 

5.  SuDDEX  h.e:morrhage  into  the  gland  or  from  it  into  sur- 
rounding tissues. 

6.  CEdema  of  the  glottis  or  of  the  mucous  membrane  of  the 
trachea.* 

1.  Direct  pressure  upox  the  trachea  may  cause :  (i)  Dis- 
placement of  the  trachea  ;  (ii)  Compression  of  the  trachea. 

(ii)  The  subject  of  displacement  of  the  trachea  has  already 
been  discussed  in  chap.  yi.  p.  101. 

(ii)  Compression  of  the  trachea  may  be  lateral,  antero- 
posterior, or,  according  to  some  authors,  circular. 

Of  these,  by  far  the  most  important  form  of  compression  is 
the  lateral.  In  comparison  with  this,  both  the  other  forms  are 
exceedinslv  rare.  Indeed,  it  is  doubtful  whether  a  true  circular 
compression  has  ever  been  observed. 

Among  all  the  thyroid  specimens  contained  in  more  than 
twenty  British  and  foreign  museums,  I  have  not  been  able  to 
find  more  than  four  in  which  any  antero-posterior  flattening 
of  the  trachea  was  present.  In  the  vast  majority  the  compres- 
sion had  been  exerted  laterally."!" 

A  typical  example  of  the  common  lateral  flattening  is  that 
from  which  Figs.  1  and  2  have  been  taken.:|: 

'-  Spasm  of  the  muscular  fibres  at  the  back  of  the  trachea  has  by  some 
authors  been  deemed  a  factor  in  the  production  of  the  dyspnoea,  but  this  theory 
does  not  seem  to  me  worthy  of  serious  consideration. 

t  For  examples  of  the  rare  antero-posterior  flattening  of  the  trachea,  see  St. 
Bart.  Hosp.  Mus.  No.  2310a  ;  St.  Marys  Hosp.  Mus.  Xo.  1031  (very  slight). 

j  St.  Bart.  Hosp.  Mus.  Ko.  2310.     For  some  examples  of  lateral  flattening 


108  THE   THYROID    GLAND. 

The  patient  was  a  boy,  aged  14,  who  died  from  dyspnoea 
produced  by  the  goitre.  liaryngotoniy  had  been  performed, 
but  was  useless,  doubtless  because  the  tube  used  was  not  long 
enough  to  reach  b^low  the  constriction. 

The  lateral  flattening  of  the  trachea,  produced  bv  goitre,  has 
long  been  known.  It  is  commonly  stated  that  attention  was 
first  drawn  to  it  by  Demme  of  Zurich,  but  it  would  appear  that 
the  credit  of  having  done  so  belongs  more  properly  to  Lullier 
AVinslow. 

The  latter  author,  writing  more  than  eighty  years  ago,  speaks 
in  the  following  terms  of  the  case  which  came  under  his  obser- 
vation. 

"La  trachea  artere  est  comme  enchattonnee  dans  la  tumeur. 
Elle  est  aplatie  lateralement  en  maniere  de  gaine  de  sabre  dans  un 
etendu  d'un  pouce  et  demi,  ayant  a  peine  (vers  le  milieu  de  cette 
partie  deformee)  inie  ligne  et  demie  posterieurement."* 

Here  we  have  apparently  the  first  accurate  description  of  this 
very  important  lateral  flattening  of  the  trachea.  Demme  at  a 
much  later  period  again  drew  attention  to  this  condition.  After 
him  Rose  (then  of  Zurich)  pointed  out  and  insisted  upon  the 
great  frequency  with  which  this  condition  occurs,  and  he  added 
a  further  statement  with  regard  to  the  changes  which  occur  in 
the  wall  of  the  trachea  as  the  result  of  long-continued  pressure. 
These  will  be  discussed  on  page  114. 

Both  Winslow  and  Demme  compared  the  shape  of  the  trachea 
when  compressed  by  a  goiti-e  to  that  of  the  scabbard  of  a  sword, 
and  the  comparison  has  been  adopted  by  most  writers  upon  the 
subject.  Among  some,  however,  the  term  "  keel-shaped  "  appears 
to  meet  with  greater  favour. 

It  will  be  seen  in  Fig.  2  that  the  point  of  greatest  con- 
striction of  the  trachea  is  rather  more  than  one  inch  below  the 
cricoid  cartilage.     This  is  the  commonest  seat  of  the  greatest 

see  the  museums  of  Roy.  Coll.  Suvg.  Eng.  Xos.  289.5,  2900  ;  Univ.  Coll.  Loiul. 
1360  ;  Guy's  Hosp.  116  ;  St.  Geo.  Hosp.  16c,  19a  ;  St.  Marys  Hosp.  1032  ;  St. 
Thomas's  Ho.«p.  1462,  1163,  146.5,  1468  ;  St.  Bart.  Hosp.  2310,  2311  ;  Oxford 
University  544a  :  Roy.  Coll.  Surg.  Edinburgh  1334  ;  also  Berne  Path.  Mus. 
B.  II.  14,  B.  II.  24. 

*  "  Obsei-vation  sur  un  goitre  volumineux  comprimant  la  trachee  artere,"' 
Bull.  dcl'Athp.MedpMrd.,  .^'v.,  Paris.  1816. 


THE   DYSPX(EA    CAUSED    BY    GOITRE.  109 

constriction  in  bilateral  goitres  of  moderate  size.  The  constric- 
tion frequently  involves,  as  might  be  expected,  a  considerable 
leno-th  of  the  trachea. 

Liebrecht  in  his  excellent  monograph  *  mentions  that  he 
removed  from  a  dead  body  a  very  large  goitre  which  had  com- 
pressed the  trachea  in  its  whole  length. 

Kocher  f  gives  excellent  drawings  of  cases  in  which  the 
trachea  has  been  extensively  compressed  and  variously  twisted 
(see  Fig.  o4).  I  have  mvself  seen  more  than  three  inches 
of  the  trachea  compressed  in  cases  in  -which  the  goitre  was  un- 
usually large. 

Influence  -which,  the  Shape  and  Situation  of  the 
Goitre  has  upon  the  Compression  of  the  Trachea. — 
Bilateral  Goitre. — It  has  often  been  stated  that  in  cases  of 
parenchymatous  goitre,  it  is  the  isthmus  especially  that  presses 
(antero-po.steriorlv)  upon  the  trachea  and  causes  dyspnoea  ;  this 
view  is  certainly  erroneous. 

If  the  whole  thvroid  gland  is  uniformly  enlarged  as  in  the 
ordinary  parenchymatous  goitre,  the  shape  of  the  compressed 
trachea  is  always  the  same.  It  is  compressed  hdcrcdhj.  never 
frovi  before  hacl-zcards.  [See  Figs.  52  and  o8c.)  Tlii>  lateral 
flattening  should  be  carefully  borne  in  mind  since  it  has  an 
important  bearing  upon  operative  proceedings  canned  out  for 
the  relief  of  dyspnoea. 

In  some  rare  cases  of  uniform  enlargement  the  whole  gland 
may  be  rotated  to  a  certain  extent  upon  its  vertical  axis,  so  that 
one  lobe  projects  a  little  more  than  the  other.  In  such  cases  the 
trachea  is  also  slightly  rotated  axially  with  the  goitre. 

If  the  gland  be  enlarged  on  both  sides,  but  more  on  one  side 
than  on  the  other,  the  flattening  of  the  trachea  partakes  more 
or  less  of  the  character  described  in  the  next  paragraph, 
according  to  the  disproportion  between  the  two  lobes. 

Unilateral  Goitre.  —  ^Vhen  the  enlargement  affects  one 
lateral  lobe  only,  the  trachea  is  flattened  upon  the  side  next  to 
the  enlarged  lobe.  (Figs.  53,  58b.)  In  these  cases  the  trachea  is 
also  more  or  less  curved  longitudinally  and  pushed  over  towards 

*  "  De  Texcision  clu  goitre  parenchymateux,"  P.  Liebrecht,  Brus5e''s,  1883, 
p.  1.').3. 

7  Langenbeck's  ArcJiirf.  hint.  Chir.,  1883,  vol.  xxix.  plate  xi. 


110 


THE   THYROID   GLAND. 


the  opposite  side.     There  is  generally  also  a  certain  amount  of 
rotation  upon  a  vertical  axis,  so  that  the  trachea  presents  an 
oblique  lateral  surface  against  which  the  enlarged  lobe  rests. 
Fig.  53*  was  taken  from  a  specimen  Mhich  I  removed  post 


Fig.  52. — Shows  the  ordiuary  Bilateral  Flattening  of  the  Trachea 

prodiieed  by  pareueliTmatoiis  yoitre  and  other  forms  of  s\-imiietrical 

eulargemeut  of  the  thyroid.    From  a  girl  ay  ed  13.  who  died  of  suffocation 

c:in.<ed  by  the  goitre. 
Fig.  .5.3. — Shows  the   ordiuary   Flattening-   and   Curving-   of  the    Trachea 

produced  by  unilateral  g-oitire.     From  a  man  aged 4 9,  who  died  of  heart 

disea.se. 
Fig.  .54. — Shows  the  Irrcg-ular  Flattening  and   Twisting-  produced   by  a 

bilateral  but  asymmetrical  goitre. 

(Figs.  -52  and  53  from  di-awing-s  by  Dr.  Ethel  Vaughan.   Fig.  54  after  Kocher.) 

mortem  from  the  body  of  a  man  aged  forty-nine,  who  had  had  a 
unilateral  cystic  goitre  for  many  years.  It  shows  well  the  usual 
curvature,  displacement  and  oblique  lateral  flattening  produced 
by  a  unilateral  goitre.     Similar  specimens  may  be  seen  in  Guy's 

*  Eov.  Coll.  Suru-.  Mils.  Xo.  2tl02c. 


THE   DYSPNCEA    CAUSED    BY    GOITRE. 


Ill 


Hospital  ^Museum,*  in  the  ^Museum  of  the  Edinburgh  College  of 
Surffeons.f  and  in  many  other  museums. 


Figs.  55  aud  56. — Larye  solid  Adenoma  of  tlie  Eiolit  Lobe,  extending: 
aci-oss  the  middle  line  and  simulating  a  bilateral  goitre.  (..See  Appendix, 
Case  90,  p.  350.) 


Xo.  171P-  (old  catalogue). 


t  Xo.  13.36. 


112 


THE   THYROID    GLAND. 


The  twisting  and  curvature  of  the  trachea  which  are  often  met 
with  and  which  have  been  well  described  and  figured  by  Professor 
Kocher,occur  almost  exclusively  either  in  cases  of  single  unilateral 
tumour  or  of  bilateral  tumour  in  which  the  two  sides  of  the 
gland  are  unequally  enlarged. 

Median  Goitre  in  which  the  enlargement  involves  the  isthmus 
alone    and    not   the    lateral    lobes. — In  this  kind  of  goitre   we 


Fig.  .37. — TliL'  same  (Fius.  5o  and  -36),  oue  week  after  enueleiition. 


sometimes,  although  rarely,  meet  with  a  slight  amount  of  true 
autero-postorior  flattening  of  the  trachea.  If  the  tumour  be 
entirely  above  the  upper  border  of  the  sternum,  then  the 
pressure  exerted  upon  the  front  of  the  trachea  is  very  slight. 
The  tumour  being  free  to  come  forwards  will  obviously  do  so 
rather  than  exert  any  appreciable  degree  of  pressure  upon  the 
trachea.  Such  goitres  scarcely  ever  cause  serious  dyspnoea. 
Fig.  42  (p.  85)  is  taken  from  an  elderly  woman  whom  I  saw  at  the 


THE   DYSPNCEA    CAUSED    BY    GOITRE. 


113 


Fig.  58. — Di:igTams  showing-  Transverse  Section  of 
Traclieal  !RingS.  a,  normal ;  b,  flatteueil  by  uni- 
lateral goitre  ;  c,  flattened  toy  bilateral  goitre. 


Bourgeois  Hospital  at  Fribourg.  It  shows  a  prominent  median 
tumour  springing  from  the  isthmus  alone.  It  produced  no 
dyspnoea. 

It  should  be  borne  in  mind,  however,  that  a  tumour  may 
present  exactly  in  the  middle  line  of  the  neck  between  the  two 
sterno-mastoids,  and  yet  not  be  a  tumour  of  the  isthmus. 
Tumours  in  this 
situation  frequently 
springfromthe  lower 
part  of  one  or  other 
lateral  lobe.  (Figs. 
43,  55,  65.)  The 
trachea  is  pushed 
over  to  the  opposite 
side  and  the  tumour, 
passing  in  the 
direction  of  least 
resistance,  comes  to  occupy  a  position  in  the  middle  of  the  neck, 
just  above  the  episternal  notch.  In  such  cases  a  careful  exam- 
ination of  the  position  of  the  larynx  and  trachea  and  of  the 
upper  portions  of  the  lateral  lobes  will  generally  lead  to  a  correct 
diagnosis. 

Occasionally  strictly  median  tumours  lie  wholly  or  partly 
behind  the  sternum.  It  is  in  these  cases  only  that  any  consider- 
able amount  of  an tero -posterior  flattening  of  the  trachea  can  be 
produced.  The  trachea  may  be  pressed  directly  backwards 
against  the  spine  by  such  a  tumour  engaged  between  it  and  the 
sternum.  Far  more  often,  however,  the  trachea  slips  to  one  or 
other  side  of  the  bodies  of  the  vertebrae  and  becomes  twisted  and 
flattened  obliquely.  In  the  specimen  at  St.  Mary's  Hospital,* 
in  which  distinct  though  slight  antero-posterior  compression  has 
occurred,  the  tumour  consists  of  a  globular  cyst  an  inch  and  a 
half  in  diameter,  situated  exactly  in  the  middle  line.  It  descended 
as  low  as  the  tenth  ring  of  the  trachea,  and  it  is  doubtless  owing 
to  its  low  situation  that  it  was  enabled  to  exert  some  pressure 
upon  the  trachea,  being  jammed  between  it  and  the  sternum. 

Changes  in  the  Wall  of  the  Trachea  produced  by  the  pres- 
sure of  a  goitre. — Professor  Rose,  then  of  Zurich,  in  an  elaborate 

*  No.  1031. 

H 


114  THE   THYROID   GLAND. 

article,*  "  Death  from  goitre  and  the  radical  cure  of  g-oitres," 
published  some  twenty  years  ago,  first  drew  attention  to  these 
changes. 

He  asserted  that  the  long  continued  pressure  of  a  goitre  would 
produce  not  only  alterations  in  the  shape  and  position  of  the 
trachea,  but  oX^o  fatty  degeneration,  softening  and  atrophy  of 
the  tracheal  wall  itself.  He  explained  further  that  owing  to 
this  alteration  in  structm'e,  the  trachea  is  more  readily  narrowed ; 
indeed  that  its  walls  might  collapse  and  entirely  prevent  the 
passage  of  air  between  them. 

It  was  to  this  cause  that  he  attributed  the  frequent  occurrence 
of  sudden  death  among  patients  afflicted  with  goitre. 

Now  there  can  be  no  doubt  that  in  the  main  these  assertions 
are  quite  justified.  The  trachea,  as  the  result  of  long  continued 
pressure,  does  become  less  resisting  and  has  a  tendency  to  collapse 
and  thus  to  produce  serious  trouble.  What  is  probably  incorrect 
is  the  statement  that  these  results  are  due  to  atrophy,  degenera- 
tion or  softening  of  the  tracheal  wall  itself.  At  first  sight  the 
theory  seems  plausible  enough.  It  is  a  well-known  law  of 
pathology  that  pressure  tends  to  produce  atrophy  if  it  lasts  for 
a  sufficient  length  of  time.  The  pressure  of  an  aneurism  against 
the  sternum  or  vertebra?  is  an  example  that  at  once  suggests 
itself. 

The  case  of  a  goitre  and  the  trachea  is  however  somewhat 
different  from  that  of  an  aneurism  and  a  bone.  A  bone  is  an 
unyielding  structure,  the  trachea  is  much  less  so.  A  very  slight 
amount  of  pressure  is  sufficient  to  cause  bending  of  the  tracheal 
wall.  This  may  be  seen,  as  has  been  already  mentioned,  in 
innumerable  museum  specimens.  Were  the  trachea  as  firm  and 
unyielding  as  a  bone  then  Ave  might  expect  to  find  atrophv 
readily  produced,  but  it  is  not  so. 

Again,  the  same  pressure  that  produces  atrophy  of  a  bone 
such  as  the  sternum  will,  if  it  continue  long  enough,  lead  to 
perforation. 

In  the  case  of  the  goitre  and  trachea,  the  atrophv  of  the  thin 
walled  trachea,  if  it  exist  at  all,  never  leads  to  actual  perforation 
Nowhere  in  any  museum,  so  far  as  I  know,  is  there  a  specimen  in 

*  ••  Del-  Kropftod  nnd  die  Kadicalcur  der  Kropfe,"  Arch.  f.  Id'in.  Chir. 
vol.  xxii. 


I 


THE    DYSPXCEA    CAUSED    BY    GOITRE.  115 

which  the  atrophy  has  gone  so  far  that  a  goitre*  has  actuaUv 
penetrated  the  interior  of  the  trachea.  Perhaps  it  may  be  said 
that  long  before  this  happens  the  patient  is  killed  by  the  pressui-e. 
Possibly  so,  but  at  any  rate  specimens  are  common  enough  in 
which  the  pressure  has  lasted  fortv  or  fiftv  vears  and  produced 
great  distortion  and  flattening  of  the  trachea  without  aiiv  pene- 
tration whatever  of  the  tracheal  wall.  Such  a  specimen  mav  be 
seen  in  the  ^luseum  of  the  Roval  College  of  Surgeons. t  But 
surely,  it  will  be  said,  there  must  be  plenty  of  museum  specimens 
showing  the  atrophic  condition  which  is  said  to  be  so  common. 
A  careful  search  for  them,  ho\\ever.  has  sho^^■n  me  that  thev  are 
conspicuous  bv  their  absence.  I  know  of  no  case  where  the 
existence  of  this  atrophv  or  fattv  degeneration  has  been  verified 
by  microscopical  examination. 

But  the  examination  has  been  made  sufficientlv  often.  Professor 
Bruns  in  an  excellent  monogra])h  "  On  the  present  state  of  our 
knowledo-e  concerning  the  treatment  of  soitre '" ~  states  that  at 
his  request  Dr.  Midler  made  a  careful  mvestigation  of  this 
subject  with  the  following  important  result : 

••  Out  of  tAventy  cases  showing  marked  compression  and  ■stenosis, 
in  no  case  was  there  any  diminution  in  the  size  of  the  rings  in  any 
direction  nor  anv  microscopical  changes  in  structure  (except  some 
calcification)  ;  in  no  case  was  anv  inflammatory  atrophy  from  com- 
pression or  softening  found." 

Dr.  Krcinlein,  Professor  of  Surgerv  at  Zurich,  in  the  course  of 
a  conversation  upon  the  subject,  informed  me  that  he  had 
examined  a  considerable  number  of  specimens  of  flattened 
trachea  and  had  never  found  the  atrophv  described  by  Rose. 

In  the  specimens  that  I  have  myself  examined,  the  rings  were 
alwavs  of  normal  thickness. 

It  mav  be  objected  that  an  examination  of  museum  specimens 
is  not  a  fair  test  of  the  presence  or  absence  of  softening  since 
these  have  usual] v  been  preserved  in  alcohol  and  have  become 

*  It  must  bn  remembered  that  these  remarks  apply  unly  to  innocent  goitre  : 
malignant  disease  of  the  thp'oid  commonly  infiltrates  and  sooner  or  later 
penetrates  the  interior  of  the  trachea. 

t  Xo.  2902c. 

i  "  Ueber  den  Gegemvartigeu  Stand  der  Ki-optTDehandlung,"  by  P.  Bruns  of 
Tiibingen,  Volkmanus  Saiuiul.  ItVin.  Yoj-trfffie,  Leipzig,  1884,  Xo.  244. 


116  THE   THYROID    GLAND. 

hardened  bv  it.  On  the  other  hand  the  actual  thickness  of  the 
wall  cannot  be  materially  altered  by  the  spirit ;  and  also,  if  such 
softened  areas  really  exist,  surely  even  after  soaking  in  alcohol 
there  ought  to  be  some  difference  between  the  hardness  of  the 
affected  areas  and  of  the  surrounding  healthy  parts.  Besides, 
many  of  the  above  mentioned  observations  were  made  upon 
recent  specimens  which  had  never  been  in  contact  with  alcohol. 

The  true  explanation  of  the  ajjparent  softening  of  a  flattened 
trachea  is  probably  as  follows. 

Professor  Rose,  being  a  surgeon  who  had  performed  many  ex- 
tirpations of  goitre,  Avas  accustomed  to  see  and  feel  the 
trachea  as  it  lay  exposed  in  the  wound,  and  he  noticed  quite 
correctly  that  that  part  of  the  trachea  which  layin  contact  with  the 
goitre  offered  less  resistance  to  the  pressure  of  the  finger  than 
did  the  neighbouring  part ;  in  fact  it  felt  softer  than  the  other. 
This  feeling  of  apparent  softening  due  to  lessened  resistance  is 
produced  however  not  by  atrophy  or  real  softening  but  by  the 
alteration  in  the  curvature  of  the  tracheal  rings.  The  accom- 
panying diagrams  (Fig.  58,  p.  113)  will  perhaps  serve  to  explain 
this  more  fully.  A  convex  surface  offers  greater  resistance  to 
pressure  than  does  a  flat  one.  The  rings  of  a  normal  trachea, 
when  exposed  in  an  operation,  present  a  convex  sui'face  offering 
a  certain  resistance  to  the  pressure  of  a  finger.  But  let  the 
curvature  be  lessened,  as  it  is  when  a  goitre  presses  upon  it, 
and  the  resistance  becomes  proportionately  diminished.  In  this 
way  a  false  sense  of  softness  is  produced.* 

I  have  been  able  to  verify  this  explanation  by  examining 
numerous  examples  of  flattened  tracheas  both  in  the  living 
subject  in  the  course  of  operations  upon  goitre  and  also  in 
museums.  The  flattened  surface  which  had  lain  in  contact  with 
the  tumour  was  found  to  be  less  resisting,  to  feel  softer, 
although  no  real  softening  or  atrophy  was  present. 

2.  We  come  now  to  the  second  mode  by  which  dyspnoea  may 
be    caused — -bv   pkessuue    upok    or    other    irritatiox    of   the 

llECURRENT    LARYNGEAL    XERVES. 

In    a   previous  chapter,  allusion  has  been  made  to  the  fact 

*  To  Pvofessnr  Kronlein  I  am  indebted  for  the  above  explanation  which  he 
made  to  liie  in  the  com-se  of  the  conver.sation  above  mentioned. 


i 


THE   DYSPNGEA   CAUSED    BY    GOITRE.  117 

that  a  goiti'OLis  tumour  may  occasionally  cause  compression  or 
irritation  of  the  recurrent  laryngeal  nerves.  Judging  from  the 
opinion  expressed  by  many  English  writers,  it  would  appear 
that  this  view  of  the  cause  of  dyspnoea  has  received  more 
support  than  has  that  which  formed  the  subject  of  the  preceding- 
section. 

The  relation  which  the  recurrent  laryngeal  nerve  bears  to  a 
thyroid  tumour  is  of  much  importance.  Most  commonly  the 
nerve  is  pushed  backwards  and  inwards  by  the  growth,  and  lies 
in  the  furrow  between  the  trachea  and  oesophagus.  Rarely  is  it 
spread  out  over  the  posterior  surface  of  the  growth. 

The  remarkable  absence  of  aphonia  and  dysphonia  in  con- 
nection with  the  dyspnoea  caused  by  goitre  would  seem  to 
indicate  that  the  dyspnoea  is  not  often  caused  by  recuiTent 
laryngeal  disturbance. 

The  paroxysmal  nature  of  the  dyspnoea  has  been  thought  by 
some  to  be  evidence  of  its  nervous  origin.  On  the  other  hand, 
it  might  be  explained  just  as  w^ell  by  supposing  that  some 
movement  on  the  part  of  the  patient  had  caused  the  already 
narrow  trachea  to  become  still  further  narrowed  by  slight 
bending  or  kinking.  It  should  be  borne  in  mind  too,  that  some 
kinds  of  goitre,  especially  the  parenchymatous,  may  undergo 
rapid  and  sudden  enlargement  from  increase  of  the  colloid 
.secretion  Avithin  it. 

That  irritation  of  the  recurrent  laryngeal  nerves  may  in  some 
cases  at  least  be  the  cause  of  the  dyspnoea  cannot,  however,  be 
denied.     That  it  may  cause  death,  is  also,  I  think,  undeniable. 

The  following  case  appears  to  illustrate  this  point  : 

Dr.  Johannes  Seitz*  of  Ziirich  was  consulted  by  a  ghl  aged  ^0 
who  complamed  of  slight  dyspnoea.  She  had  a  sniad  goitre  which 
did  not  appear  to  be  very  serious.  In  the  middle  of  the  following 
night  she  was  suddenly  seized  with  a  paroxysm  of  dyspnoea  and  died 
in  a  few  minutes.  At  the  post  mortem  a  small  parenchymatous 
goitre  was  found,  but  the  trachea  appeared  to  be  little  if  at  all  com- 
pressed by  it.  No  other  cause  for  the  dyspnoea  could  be  found. 
There  could  be  no  doubt  from  the  history  of  the  case  that  the  girl 
had    died    of   dyspnoea.      The    conclusion,  therefore,  Avas  that   the 

*  Dr.  Seitz  has  published  this  case  iu  full  in  au  able  paper  upon  this  subject. 
t' Der  Kropftod  durch  Stimmbandlalimung,"  Arch.f.  Jdin.  Chit:,  1883. 


118  THE   THYROID   GLAND. 

growtli  of  the  goitre  had  irritated  the  recurrent  nerves  in  such  a 
way  as  to  set  up  fatal  spasm  of  the  glottis.*  Dr.  Seitz  was  kind 
enough  to  allow  me  to  examine  the  specimen  critically  and  I  could 
find  no  evidence  to  disprove  tlie  conclusion  at  which  he  had 
arrived. 

There  are  two  theories  as  to  the  mode  in  which  the  affection 
of  the  laryngeal  nerves  may  cause  dyspnoea,  namely,  by  causing 
(a)  spasm  of  the  adductors  of  the  vocal  cords ;  (b)  paralysis  of  the 
abductors. 

The  first  theory  is  a  very  ancient  one,  the  second  is  more 
especially  associated  with  the  name  of  Sir  Felix  Semon.  The 
latter  has  shown  that  in  cases  where  the  recurrent  nerve  has 
become  gradually  paralysed  by  pressure,  as,  for  example,  by  an 
aneurism,  it  is  the  abductors  that  are  first  affected,  and  that  the 
adductors  remain  intact  for  a  longer  time.  The  effect  of  this 
earlier  paralysis  of  the  abductors  is  to  cause  considerable  and 
dangerous  dyspnoea  which  may  prove  fatal  if  both  nerves  are 
affected  simultaneously.  The  dyspnoea  tends  to  diminish  as 
the  paralysis  advances  and  the  cord  assumes  the  cadaveric 
position.  Of  the  truth  of  this  assertion  there  can  be  no  reason- 
able doubt.  But  whether  this  is  what  usually  happens  when  a 
goitre  presses  upon  the  recurrent  nerve  is  much  less  certain. 
'J^he  paroxysmal  nature  of  the  dyspnoea,  in  many  cases,  if  due  at 
all  to  an  affection  of  the  nei'ves,  woiild  seem  to  point  rather  to 
a  spasmodic  than  to  a  paralytic  affection  ;  in  cases  where  the 
dypsnoea  is  more  persistent  and  continuous,  it  is  perhaps 
possible  that  the  paralytic  theory  may  apply. 

3.  By  direct  extexsiox  ixto  the  ixterior  of  trai'hp:a  or 
LARYXx. — In  simple  goitre,  that  is,  in  any  non-malignant  form 
of  the  disease,  this  never  occurs. 

In  malignant  disease  of  the  thyroid,  on  the  other  hand,  such 
ingrowth  does  usually  take  place,  and  frequently  it  is  the 
cause  of  death.  The  larynx  is  perforated  much  less  often. 
This  is  but  natural,  since  the  larynx  is  not  situated  in  such 
intimate  relation  with  the  thyroid  as  is  the  trachea. 

It  would  seem  that  hydatid  cysts,  unlike  other  cysts  of  the 

*  It  is  conceivable,  however,  that  the  suddenly  compressed,  elastic  trachea  of 
a  young- person  might  regain  its  normal  calihi-e  when  removed  fi'om  the  body 
and  thus"  relieved  from  external  pressure. 


THE   DYSPNCEA   CAUSED    BY    GOITRE.  119 

thyroid,  are  apt  to  cause  absorption  of  the  tracheal  wall. 
Examples  are  quoted  by  Dardel  in  his  thesis  on  the  subject.* 

4.  By     RUPTUIIE     OF     A     CYST      OK     AN     ABSCKSS      INTO     THE     ATR 

PASSAGES. — A  few  cases  have  been  recorded  in  which  a  thyroid 
cyst  or  abscess  has  burst  suddenly  into  the  trachea,  larynx,  or 
pharynx,  and  the  discharge  of  pus  or  other  fluid  has  caused 
immediate  suffocation. 

Sir  James  Paget  f  mentions  the  case  of  an  elderly  woman 
under  the  care  of  Mr.  Vincent ;  rupture  of  a  suppurating 
thyroid  cyst  into  the  pharynx  produced  immediate  asphyxia 
and  death. 

A  surgeon  who  is  treating  a  suppurating  cyst  should  bear  in 
mind  the  possibility  of  such  a  fatal  termination. 

Cases  of  sudden  death  caused  by  the  rupture  of  a  hydatid 
cyst  will  be  found  in  the  table  appended  to  chap.  xi. 

5.  By  causing  gedema  of  the  glottis. — OEdema  of  the  glottis 
sometimes  complicates :  (i)  Inflammation  of  the  thyroid,  and 
(ii)  Malignant  disease. 

It  is  not  difficult  to  understand  how  inflammation  of  the 
thyroid  may  easily  spread  to  a  part  so  near  to  it  as  the 
glottis. 

Many  years  ago  I  had  the  opportunity  of  seeing  a  case  in 
which  a  swelling  of  the  thyroid  gland  caused  such  dyspnoea  that 
an  attempt  was  made  to  perform  tracheotomy.  Laryngo- 
scopic  examination  before  the  operation  disclosed  considerable 
(fidema  of  the  glottis.  The  relief  aftbided  by  the  incision  into 
the  gland  and  the  rapid  disappearance  of  the  tumour  were  sup- 
posed to  confirm  the  diagnosis  of  inflammation  of  the  thyroid. 
This  seems  to  have  been  a  case  in  which  the  dyspnoea  was 
produced  by  oedema  of  the  glottis. 

Reverdin^  of  Geneva,  whose  experience  of  goitre  has  been 
very  large,  remarks  that  oedema  of  the  glottis  does  not  occur 
in  cases  of  simple  goitre,  although  it  is  occasionally  met  with 
in  malignant  disease. 

The  oedema  of  surrounding  parts  produced  by  the  latter 
disease  requires  no  special  explanation  or  illustration. 

*  See  chap.  xi. 

t  "  Lectures  on  Surgical  Pathology,"  1876,  p.  401. 

X  Berue  Medicale  de  la  Suisse  Romande,  1882,  p.  173. 


1^20  THE   THYROID   GLAND 

6.  By  causing  swelt.ixg  of  the  mucous  membuaxk  ok  the 
TRACHEA. — It  is  Only  in  cases  where  the  trachea  has  ah'eady  been 
greatly  narrowed  by  pressure  from  without  that  the  slight  extra 
amount  of  narrowing  thus  produced  could  lead  to  dyspnoea. 

In  cases  of  inflammation  of  the  thyroid,  the  mucous  membrane 
of  the  neighbouring  trachea  may  perhaps  be  directly  aft'ected  by 
extension  of  the  inflammation  to  it. 

Idiopathic  bronchitis,  or  more  strictly  tracheitis,  may  also 
produce  dyspnoea  in  cases  where  the  trachea  is  already  narrow. 
Allusion  has  already  been  made  to  the  fact  that  the  trachea  may 
be  considerably  narrowed  by  the  pressure  of  a  goitre,  and  yet  no 
dyspnoea  be  present.  But  let  such  a  patient  be  attacked  by 
bronchitis,  or  even  by  an  ordinary  cold,  and  the  dyspnoea  may 
speedily  become  alarming. 

Goitrous  patients  frequently  say  that  their  breathing  never 
gives  them  any  trouble  except  when  they  have  caught  cold. 

In  the  preceding  portion  of  this  chapter,  we  have  been  engaged 
in  considering  the  various  modes  in  which  the  dyspnoea  may  be 
produced  by  goitre. 

We  have  now  to  consider  a  subject  closely  related,  namelv, 
the  age  and  sex  of  the  patient  and  the  varieties  of  goitre  that 
are  most  likely  to  produce  dyspnoea,  and  especially  such 
dyspnoea  as  will  endanger  life. 

Careful  study  of  this  subject  must  obviously  have  an  important 
bearing  upon  the  prognosis  and  treatment  suitable  to  any  given 
case. 

Although  dyspnoea  is  such  a  common  symptom  in  patients 
sufi^ering  from  goitre,  yet  it  varies  greatly  in  degree  in  dift'erent 
cases.  Moreover,  those  who  have  published  cases  have  described 
the  dyspnoea  in  such  different  terms  that  it  is  difficult,  from 
mere  published  reports  to  draw  accurate  conclusions  as  to  the 
varieties  of  goitre  most  likely  to  cause  serious  dyspnoea. 

The  table  on  pp.  126-129  affords  some  help  in  the  study  of 
this  subject.  It  includes  all  those  cases,  and  those  cases  only 
that  I  have  been  able  to  find,  in  which  the  dyspnoea  was  clearly 
so  extreme,  that  death  resulted  from  it  and  from  it  alone.  It 
will  be  seen  that  it  includes  cases  in  which  no  operation 
was    performed,    and    also   those    in    which   the    death    seems 


THE   DYSPNOEA   CAUSED   BY   GOITRE.  121 

attributable  clearly  to  the  dyspnoea,  and  not  to  the  opera- 
tion.* 

In  order  to  eliminate,  as  far  as  possible,  any  source  of  error 
arising  from  the  latter  point,  no  case  has  been  included  in  which 
the  operation  was  anything  more  than  a  simple  tracheotomy  or 
larvngotomv. 

If  cases  in  which  more  severe  operations,  such  as  extirpation 
or  enucleation,  had  been  included  in  the  table,  the  number 
could  have  been  enormously  increased,  since  it  is  usually 
dyspnoea  which  has  led  to  the  performance  of  these  more 
serious  operations.  But  it  is  so  difficult  to  be  quite  sure  how 
far  the  death  ni  such  cases  is  attributable  to  the  dyspnoea  and 
how  often  to  complications  arising  from  the  operations  them- 
selves, that  their  inclusion  would  have  seriously  impaired  the 
statistical  value  of  the  table. 

The  table  gives  details  of  thirty-four  cases  from  the  following 
sources :  In  eight  the  actual  goitre  has  come  under  my  notice 
in  museums,  the  history  having  been  in  most  cases  obtained 
from  the  museum  catalogue  ;  seven  cases  have  been  personally 
communicated  to  me  by  the  practitioners  under  whose  care  the 
patients  were  ;  the  remaining  nineteen  have  been  obtained  from 
various  medical  journals  and  hospital  registers. 

In  an  examination  of  the  table  the  first  point  that  may  be 
noticed  is  that  of  the  whole  thirty-four  cases,  no  less  than 
seventeen  (i.e.,  just  half)  occurred  in  patients  of  the  male  sex. 
It  is  well  known  that  goitre  occui's  much  more  frequently  in 
female  than  in  male  patients.  It  might  therefore  naturally  be 
expected  that  cases  of  fatal  dyspnoea  would  be  much  more 
common  among  the  former.  Such,  however,  does  not  seem  to 
be  the  case.  Fatal  dyspncea  occurs  with  nearly  equal  frequency 
in  both  sexes  despite  the  fact  that  innocent  goitre  is  much  more 
common  in  the  female  sex. 

The  next  point  to  be  noticed  is  that  the  great  majority  of 
the  patients  were  voung  adults  under  the  age  of  twenty.      Of 

*  It  will  be  seen  also  that  a  lai*ge  and  imf)ortant  class  of  cases,  namely  those 
of  malignant  disease,  has  likewise  been  omitted.  These  cases  have  been  omitted 
because  dyspnoea  of  a  severe  and  generally  fatal  nature  is  almost  always  present 
in  patients  suffering  from  malignant  disease  of  the  th3'roid  ;  the  cause  of  the 
dyspnoea  in  these  cases  is  generally  different  from  that  which  pertains  in  cases 
of  innocent  goitre,  being  so  often  due  to  direct  extension  of  growth  into  the 


122  THE   THYROID    GLAND. 

the  twenty-nine  cases  in  which  the  ao-e  is  given  only  seven  were 
above  twenty,  while  the  voungest  was  twelve.  Three  (|uarters 
of  the  patients  were  between  the  ages  of  twelve  and  twenty, 
and  of  these  no  less  than  thirteen  (more  than  one  third  of  the 
total  number)  were  between  the  ages  of  thii'teen  and  sixteen. 
Of  the  five  whose  exact  ages  are  not  given  two  were  "young 
adults,"  and  it  is  at  least  highly  probable  that  they  were  under 
twenty.  Of  the  seven  whose  ages  are  stated  definitely  to  be 
above  twenty,  one  was  only  23,  the  others  29, 30,  and  SS  respec- 
tively ;  it  may  be  noticed  that  the  last  four  were  all  women. 

If  we  may  draw  conclusions  from  these  figures  it  appears  that 
the  age  at  icluch  fatal  dyspnoea  is  most  likely  to  occur  is  that  of' 
puberty  or  soon  after,*  and  that  at  a  later  age  it  is  women  and 
not  men  that  are  most  likely  to  be  the  victims  of  dyspnoea. 

In  what  way  may  this  relation  to  age  and  sex  be  explained  ? 

In  most  of  the  above-mentioned  cases  the  goitre  was  of  the 
parenchymatous  variety,  that  is  the  enlargement  of  the  thyroid 
was  caused  chiefly  by  an  increase  in  glandular  elements  attended 
by  an  abnormal  accumulation  of  the  colloid  contents  of  the 
vesicles. 

In  most  cases  of  goitre  occurring  in  young  subjects  we  find 
that  this  is  the  nature  of  the  tumour.  In  older  patients,  on  the 
other  hand,  we  as  often,  or  more  often,  meet  with  unilateral 
swellings,  cysts  or  cystic  adenomata. 

There  cannot  be  much  doubt  also  that  the  more  acute  the 
goitre,  that  is  the  more  rapidly  it  has  grown,  the  more  severe 
will  be  the  dyspnoea. 

One  reason  why  young  people  are  more  liable  to  dangerous 
dyspnoea  is  because  in  them  the  trachea  is  softer,  more  yielding, 
and  therefore  more  easily  compressed  than  in  older  people. 
Another  reason  is  that  in  them  the  goitre  is  usually  of  the 
bilateral  parenchymatous  variety  which  can  compress  the  trachea 
more  effectually  than  a  unilateral  goitre.     Thirdly,  parenchy- 

air-passages.  The  age  of  sucli  patients  is  usually  much,  greater  than  those  of 
the  vast  majority  of  patients  of  the  other  class.  Such  a  distinct  class  then  do 
these  cases  form  that  by  mixing  them  with  the  others  we  should  only  arrive 
at  more  confused  and  less  accurate  deductions. 

*  It  may  be  added  that  this  statement  is  confirmed  by  an  examination  of  the 
much  larger  number  of  those  cases  in  which  major  operations  have  been  per- 
formed, but  which  do  not,  for  reasons  stated  above,  appear  in  the  table. 


THE    DYSPNCEA   CAUSED    BY   GOITRE.  123 

raatous  goitres  are  especially  apt  to  develop  rapidly  about  the 
age  of  puberty.  The  rapid  development  at  this  age  may 
perhaps  be  due  to  the  close  connection  which  appears  to  exist 
between  the  thyroid  gland  and  the  genital  system.* 

Increasing  parenchymatous  goitres  in  persons  over  the  age  of 
twenty  are  usually  seen  in  women,  and  in  a  large  number  of 
cases  during  pregnancy. f 

The  enlargement  of  the  thyroid  gland  which  is  said  to  occur 
during  menstruation  has  already  been  mentioned.  Certainly  at 
these  periods  a  goitre  is  very  apt  to  swell  and  cause  respiratory 
troubles. 

In  middle-aged  and  elderly  patients  a  variety  of  goitre  which 
sometimes  leads  to  serious  or  fatal  dyspnoea  is  that  form  of 
cystic  goitre  to  which  the  term  " haimorrhagic  goitre"  has  been 
given. 

The  tumour  generally  contains  one  or  more  large  cysts  into 
which  hfemorrhage  suddenly  occurs  (cases  3,  5  and  30  in  the 
table),  or  the  tumour  may  give  way  at  some  part,  generally  the 
posterior,  and  blood  mixed  with  the  other  contents  of  the  cyst 
may  diffuse  itself  into  the  surrounding  tissues,  causing  pressure 
upon  the  trachea  or  perhaps  upon  the  recurrent  nerves.  For 
examples  of  this  accident  see  Heidenreich  and  Dewes.  I 

Osier  has  published  §  the  following  case  of  fatal  haemorrhage 
into  a  large  bronchocele  : 

The  patient  was  an  insane  woman  aged  44,  who  died  from 
spontaneous  haemorrhage  into  a  large  bronchocele.  While  at  work 
she  became  faint,  breathless  and  blanched,  and  died  in  a  few  hours. 
An  immense  goitre  which  had  existed  for  many  years  occupied  the 
entire  space  between  the  chin  and  sternum.  At  the  post-mortem 
examination  "  a  space  was  opened  between  the  bronchocele  and  the 

*  It  is  possible  that  the  greater  enhirgement  of  the  Uiryiix  and  trachea  which 
takes  phice  at  puberty  maj^  have  some  share  in  the  production  of  the  dyspncea 
in  boj's. 

f  See  Jenks  "  On  the  Kehition  of  Goitre  to  Pregnancy,  &c.,"  Aiii,ei:  Jcmrn.  of 
Ohst.,  1881,  vol.  xiv.  p.  1.  Also  Lawson  Tait  "  On  Enlargement  of  the  Thyroid 
Body  in  Pregnancy,"  Tram.  Edln.  Ohst.  Sue.  iv.  81-95. 

I  "  8chneller  Tod  dtirch  das  Bersten  einer  Schilddriisencyste  und  die 
Trachea  comprimirende  Blnterguss,"  Corre.^-j^ondctizMatt  Bayer.  Aerzfe,  1811, 
quoted  by  Seitz. 

§  "  Fatal  Hemorrhage  into  a  Large  Bronchocele,"  John  Hopkins  Ho.f p.  Bull., 
Baltimore,  1889-90,  i.  p.  23. 


124  THE   THYROID    GLAND. 

sternum,  containing  large  clots,  which  on  dissection  were  found  to 
have  come  from  one  of  the  lower  cj'sts  of  the  goitre  which  had  rup- 
tured. The  blood  extended  into  the  cellular  tissue  of  the  neck  and 
beneath  the  sternum  into  the  anterior  mediastinum,  covering  the 
aorta  and  upper  part  of  the  pericardium.  The  haemorrhage  passed 
behind  the  pharynx  and  down  the  course  of  the  oesophagus  for  two 
or  three  inches.  On  removal,  the  windpipe  and  gullet  were  found 
almost  completely  embedded  in  the  goitre,  and  the  foi-mer  seemed 
at  its  lower  pai't  somewhat  compressed.  The  bronchocele  weighed 
1~  kilograms,  and  was  of  the  parenchymatous  variety  ;  here  and 
there  were  cysts." 

Dr.  Osier  in  his  remarks  upon  the  case  says  that  it  was  difficult 
to  determine  whether  this  patient  died  directly  from  loss  of 
blood  or  from  the  mechanical  effects  of  pressure.  It  is  unfor- 
tunate that  no  note  has  been  made  of  the  state  of  the  veins. 
From  the  description  of  the  hsemorrhage  it  seems  likely  that 
the  blood  was  derived  from  one  of  the  thinned  and  greatly 
distended  veins  that  usually  ramify  upon  the  surface  of  large 
goitres. 

Occasionally  a  cyst  undergoes  rapid  enlargement  owing  to 
excessive  inflammatory  secretion  into  its  interior.  A  case  that 
I  saw  with  Mr.  Bowlby  at  St.  Bartholomew's  Hospital  a  feA\' 
years  ago  illustrates  this  point.* 

A  woman  was  admitted  with  a  tense  elastic  swelling  at  the  lower 
part  of  the  thyroid  gland.  The  swelling  lay  largely  behind  the 
sternum.  It  had  recently  increased  considerably  in  size  and  caused 
extreme  dyspnoea.  The  cyst  Avas  incised  and  found  to  extend  so 
far  down  behind  the  sternum  that  we  could  both  see  and  feel  the 
arch  of  the  aorta  and  the  chief  vessels  arising  therefrom.  The  cyst 
wall  was  so  intimately  connected  with  these  vessels  that  enucleation 
would  have  been  imjoossible.  The  huge  cavity  was  packed  with 
gauze  and  the  patient  made  an  excellent  recovery. 

In  this  case  it  seems  probable  that  an  inflammatory  condition 
of  the  cyst  led  to  the  hypersecretion  into  it  and  the  consequent 
severe  dyspnoea. 

With  the  exception  of  these  cysts  suddenly  increasing  from 
haemorrhage  or  other  cause,  and  tumours  which  are  substernal, 
unilateral  goitres  do  not  often  cause  fatal  dyspnoea. 

*  This  case  has  been  published  in  the  Luiirrt,  189.">,  i.  IIIS. 


THE   DYSPNGEA   CAUSED   BY   GOITRE.  125 

The  degree  of  prominence  of  the  tumour  is  of  importance  in 
relation  to  dyspnoea.  The  more  firmly  a  goitre  is  held  down  by 
resisting  structures  such  as  fascia  or  bone  (sternum),  the  more 
likely  is  it  to  cause  serious  respiratory  trouble.  Thus,  some  of 
the  most  danoerous  tumours  are  those  which  lie  behind  the 
sternum  and  which  send  down  prolongations  into  this  region 
(substernal  and  aortic  goitres,  "goitres  plongeants"  of  French 
authors). 

In  countries  where  goitre  is  prevalent  one  often  sees  huge 
prominent  and  even  pendulous  tumours  causing  comparatively 
little  dyspnoea.  Fig.  46  shows  such  a  case.  As  examples  of 
the  opposite  condition  in  which  the  goitre  causes  hardly  any 
external  swelling  may  be  cited  the  case  recorded  on  p.  105,  and 
that  of  the  boy  whose  goitre  is  now  in  St.  George''s  Hospital 
Museum.* 

In  the  latter  case  although  gradually  increasing  dyspnoea  had 
been  present  for  sixteen  months  yet  no  external  tumour  was 
noticed  until  three  days  before  death,  which  occurred  from 
suffocation. 

Strictly  median  tumours,  not  involving  the  lateral  lobes,  are, 
as  has  already  been  explained,  extremely  rarely  the  cause  of 
dyspnoea. 

There  are  some  reasons  for  believing  that  the  bilateral  fibrous 
goitres  of  adults  are  especially  liable  to  cause  severe  dyspnoea. 
Several  cases  have  come  under  my  observation  which  seem  to 
support  this  view. 

One  was  that  of  an  elderly  woman  seen  with  Dr.  Favre  at 
Fribourg  (Switzerland)  in  1886.  This  patient  had  a  very  small 
hard  goitre  which  appeared  to  be  shrinking  in  size  and  causing 
increasing  and  severe  dyspnoea  as  it  did  so. 

Other  cases  are  described  in  the  following  chapter. 
*  Xo.  liJB.     Also  case  2  in  the  lable. 


126 


THE   THYROID   GLAND. 


'XI 
Oh 

w 

IX! 


X 


3   @ 
o  ^ 


< 


H 

O 
O 


en 
en 


o 

I— ( 

< 


^ 

_ 

.,r^ 

X  £  5^ 

^ 

^ 

■/, 

■A      ? 

■l_ 

^ 

'~ 

:;    5 

S 

S 

i 

P 

0 

^  r 

5 

^ 

5: 

M 

^  t^  '•' 

J" 

2 

M 
^ 

^ 

:^ 

-•  CO 

7*50 

-  '^ 

=  ^ 

X 
X 

1 

'X. 

<:; 

■3 

.=-  ..  d 

-i  -«  ■-« 

^  ^  X 

•" 

C3 

> 

H 

^."^ 

^.= 

1 

7" 

1 

=  — -^ 

•'I- 

X 

t5 

-ic 

X   2 

^ 

X 

a 

^    V. 

>.  O   cS 

>i 

_ 

_ 

, — ^    -M     (1> 

? 

*x 

ftl 

if. -f 

£_;. 

ir. 

^ 

t; 

"t^ 

=  •? 

- 

- 

£ 

5 

^^      &(<+-( 

' — 

bt 

—  **-' 

X 

^  -^ 

— 

— 

— 

X 

-^^  o 

^ 

^ 

■r; 

-  ^ 

-T" 

r  — 

-r 

~i 

if. 

a; 

?'o   ^ 

"^ 

\ 

£ 

If  2 

-M 

it  C 

- 

u 

i  5  •- 

r 

^ 

a; 

-tJ  _o 

c 

^  ^ 

- 

£ 

2 

^ 

C  -  aj 

5 

;i: 

jt 

2  "^ 

-t-* 

—    1-' 

"t^ 

— 

— 

_.  ..--C 

^ 

■p 

"    rQ 

3 

—    r~ 

3 

— 

rj 

1) 

ij 

5l 

II 

1 

= 

r-<  ^   t- 

H 

H 

5  ^ 

^ 

r. 

.  ^ 

'-7- 

>-. 

■■::■__ 

> 

:= 

::• 

^ 

^  "^ 

a  T" 

~ 

^ 

X^   "~ 

" 

s 

-; 

05 

o^ 

w' 

—  .z 

C 

—  ..II 

!?; 

^ 

■^ 

— 

o  "H3 

^ 

c  — 

^ 

■^ 

3     '"P 

o 

"^ 

;^ 

z 

2  " 

-75    o 

:^ 

it  ■- 

_5 

.t; 

-5     - 

'< 

i  c 

r-  = 

i 

>. 

^     - 

a 

M 

="' 

— 

~ 

> 

^ 

o 

5 

1^? 

X 

■^ 

53 

1 

It 

II 

^ 

:^ 

11 

-r-*^  1- 

^ 

_i 

■? 

^3  3' 

_ijr  'Z 

■Z  ■' 

■"5 

"3 

>  0 

■S  ""    be 

f 

1 

,g 

^ 

?  5 

'X    C 

f.  p. 

5 

g 

~  s 

i^TS   tT 

c 

JC 

J6 

z 

o  S^ 

o 

1 

^ 

?^  '~' 

^ 

^ 

■"^ 

..  -M 

^ 

~>" 

=  -^ 

2 

^, 

^. 

1 1 

c 

•"— 

.a 

-/- 

ic  2 

o 

5 

1 

5. 

^ 

1 

/— s 

s 

1  1 

^ 

|-p 

^ 

:;  |f- 

5 

x 

3 

P 

^. 

3    i 

a 

^ 

=  ■$ 

1^ 

;I  '>' 

z- 

'"'  /- 

B 

GC 

b£ 

S 

9 

■■? 

>  Tf. 

1 

-=  "i 

I- 

l^ 

" 

c 

'3'S 

^ 

*~    v; 

r'- 

— 

**  ."** 

X 

'J3  7. 

5 

:;; 

::5  " 

0 

^ 

— 

ft 

t~ 

»;; 

/^> 

(M 

3J 

>— 

1- 

ri 

z     . 

»— < 

^H 

^ 

a; 

'^^ 

^- 

<  w 

^ 

^ 

-:: 

■^ 

^ 

-^ 

::. 

"E 

?1  ^ 

"Z^ 

"H 

i 

^ 

= 

53 

= 

~r. 

Z 

g 

i 

S 

"-^ 

33 

&H 

:Z 

S 

i 

© 

1—1 

N 

cc 

-* 

.--: 

vc 

l^ 

X 

THE    DYSPXCEA   CAUSED   BY   GOITRE.  127 

j;  !5        3d    r       be 


C2 


J-  ■"  a  _j-  "  2  S  =g  ^_  J  •§  ^  J 'S     'S  ^  5  5  J  S  i  ►^  ^  J  J  ■" 


So  I  '^        :^-=      =  I  2  g         g  i ''=      1. 2 


P  H»l 


i^f  i  1^  1 1  'it     I        i        1 1-|  i  =     S        2     If  2 

IfSlil        11    !^      ^      l^ll^    ^      ^    1f^ 

1-3  H  "S  r^    "  -'-    ?r  •^r2  "      S 


Ci   :r 


:/■ 

.T' 

"ti 

H 

J- 

* 

S 

X 

- 

-W 

o 

"N 

^ 

^ 

Pi 

J 

i 

1) 

"3 

X 

> 

3  be  r  :S  1) 


128 


THE   THYROID   GLAND. 


0 

"E. 

ZlJ 

2 

"r  -+- 

S 

-*■ 

5 

^ 

H  X 

.^ 

bf. 

g 

t' 

=^'S 

cc 

^  ^ 

^ 

S 

d 

-5  ~t" 

J> 

'^. 

f> 

^ 

ii  ^ 

■z 

>■"? 

'§ 

^2 

o_^  ^ 

X 

K 

•J. 

a. 
-A 

-2 

X 

X 

">•. 

X 
H 

1 

S 
X 
^ 

-f  .5 

u. 

S 

■JL 

X 

>* 

x' 

V 
X 

X 

H  X  '  • 

_, 

"T" 

17 

./. 

, 

li 

1; 

s 

"S 

= 

5  ;pN 

x".^ 

^ 

>. 

g 

:! 

S-^  J 

3 

'x 

^ 

•■^ 

^ 

j3  ^ 

ce 

^-T    r^ 

J 

-^  J^ 

g 

2 

ci 

"x 

to 

^  r  'i 

-5 

5 

-^ 

X 

x" 

•J. 

S  ^ 

8 

X 

Q'3 

c 

c 

_o 

0   <a 
X    ^ 

X 

bt 

aj 

53 

X 

0^ 

p 
'6 

5 

X 

11 

~t3 

s. 

:5 

"ii 

r^ 

^ 

i  ? 

IT 

— ;i: 

C' 

53 

- 

_g 

X 
X 

j; 

'~ 

c^' 

3 

5  -n 

2^3 

1 

a. 

X 

0 

0  ■* 

a. 

X  "" 

0, 
c: 

Y^ 

X 

X 

■:i: 

^ 

^ 

.2 

1; 

3 

-fj 

cs  0 

a 

""^  ^ 

X 

S 

-^ 

|j 

111 

>. 

'« 

-r-J 

CC 

p 

H 

X    = 

"^ 

1 

p 

S      -^ 

1^ 

0 
0. 

3 

c5    '-' 

-H3 

x> 

^ 

0 

0 

a 

K 

.^ 

fl 

0  a> 

< 

c 

- 

0 

00^ 

o 

1 

^-^ 

0 

a; 

0 
0 

c 

'i^ 

-S 

3 

0 

0 

_0   cs 

t^ 

0 

+^ 

> 

cS 

St-  &| 

H 

1 

I'S 

e- 

H 

•p-H 

s-*^ 

0 

'a3 

J 

^.^ 

, , 

"■ 

i; 

>> 

(3 
cs 

M 

o 

c 

o 

s 

S  ^ 

^ 

^'     X 

X 

^0 

Oj 

.5 

S 

Ti 

S  'be 

>-. 

'c 
bj; 

£  c^' 

4 

-z 

" 

10 

.-  ° 

'J 

•a, 

.0. 

5  ^ 

0 

-2 

0 

a; 
bi: 

■"    a^ 

"3 

"5; 

"0 

=2  c 

3 

X 

pS  "3 

K 

a 

< 

6' 

1.2 

t-     X 

b/a 

1-1 

X 
K 

X  § 

/^** 

5  S 

g 
0 

CO 

5  9 

5' 

5- 
a. 

ST 

1 

CO 

£   0 

1^ 

0 
c; 

/~^ 

X   ■' 

ll 

1 

II. 
ai-i 

CO 

^,2 

1^1 

cc  0  a; 

c: 

^ 

."§ 

^ 

cc 

S   >-' 

'J. 

^ 

B 

X     ^ 

> 

y  X 

i  S 

^_^ 

cS   ei   ■- 

-f 

'^ 

= 

1 

,'K 

^ 

g 

^ 

p. 

■5  5 

0  ^ 

^ 

=  < 

0  1* 

^ 

CC 

3 

,— 

CO 

10 

c 

t— ' 

cc 

CO 

cc 

(>) 

!— ' 

0 

T— ( 

S5     . 

1/ 

C^l 

IJ 

d; 

■a. 

^ 

aj 

ij 

"g 

?. 

5 

^ 

2 

% 

ct: 

13 

t 
^ 

§ 

;£ 

il 

£ 

'^ 

1 

S 

0 

^ 

(M 

CC 

•+ 

,- 

._- 

t^ 

X 

1= 

(M 

(M 

c^l 

IM 

w 

55 

N 

5q 

THE   DYSPN(EA   CAUSED   BY   GOITRE.  129 


&0M 


=4H   ^  ao 


i'i"  11^13       «4-   sis 


1  bti        c 


0^ 

r^ 

3              „05 

iJ 

.-C 

G  05  -r  .«■ 

o 

ll  COl 

(188 
890, 

;^ 

a  ^K^ 

(^ 

P-, 

a-3  g 

r         "^ 

a 

'^  -i;  J  ^  o  ?? 


=.£SS7?°       c-ScsS  cs  -ecu:      ^S.:i.os.S;;^, 


o  s 
0-2 


"^    1— 1 

CD 

a 

OJ     r-i 

0 

a 

H 

0-+^     ^--S     "rQ     O  ^     .,     n     '^ 

ja  ^  — .  S  o  r^  bc^  S  t"^  ^  '^  '^-  ?■■ 


a:) 


a    '  a  '•'^  "^ 


5  o 


c  ^  -^  .a  =s  °  -s  ^  ci  *  CD  a  a  c 


:3  .2  S  o  -+5  -tS  -s  vV  ? 


a  W 


a  c  bcQ  -•  > 


cc    Oj 


3555^  ^  ^S         '3  a&: 

■^bcS,  2  "Ba  ^  >"'^ 

&  g  ^.         -3  ft 


5|| 


p 


CHAPTER   VIII. 

INFLAMMATION. 

Acute  idiopathic  inflammation — TAi^hoid  fever — Rheumatism — Pj'<emia 
— Traumatic  inflammation — SAmptoms — Results  of  suppuration — Diag- 
nosis— Treatment.  Chronic  inflammation — Primary  chronic  inflamma- 
tion— Diagnosis  from  malignant  disease — Treatment. 

Acute  inflammation  may  attack  a  previously  normal  thyroid  or 
one  that  is  already  the  seat  of  goitre.  Inflammation  of  a  goitre 
is  most  often  seen  as  the  result  of  some  operation,  such  as 
injection.  Inflammation  due  to  any  other  cause  is  one  of  the 
least  common  affections  of  the  thyroid. 

Idiopathic  inflammation,  whether  of  the  normal  or  of  the 
goitrous  thyroid,  has  been  observed  most  often  in  the  course  of 
one  of  the  exanthemata  or  of  some  other  acute  febrile  disease 
and  o-enerallv  at  a  late  stage. 

Of  these  diseases  the  following  are  the  most  important : 

Typhoid  Fever. — The  occurrence  of  abscess  in  various  parts 
of  the  body  in  the  later  stages  of  typhoid  fever  is  such  a  well- 
known  complication  of  that  disease  that  it  is  not  surprising  to 
find  that  the  thyroid  gland  is  sometimes  the  part  affected.  The 
occurrence  of  this  form  of  thyroiditis  was  probably  first  mentioned 
by  Baumann  in  1856.* 

Abscess  of  the  thyroid  is  a  late  complication  of  typhoid  fever, 
rarely  occurring  before  the  fourth  week  and  often  very  much 
later. 

Rheumatism,  first  mentioned  by  Molliere.t  The  inflamma- 
tion due  to  this  cause  appears  to  differ  from  that  caused  by 

*  "  Ueber  die  Vereiterung  der  Schilddriise,"  Inaugural  Dissertation,  Zurich, 
1856. 

t  Mpiii.  Siir.  Sr.  Mt'd.,  Lyons,  1873,  }).  2.5.  See  also  Ricklin,  Gaz.  Med., 
Paris,  188.0,  p.  4i8,  and  Zoniovitch,  "  De  la  thjToidite  aigue  rhumatismale," 
The^<h,  Paris,  1885. 


INFLAMMATION.  131 

typhoid  in  that  the  inflammation  rarely  proceeds  to  suppuration, 
whereas  in  typhoid  fever  abscess  is  frequently  the  result.  Sir 
Thomas  Barlow  *  has  recorded  a  case  which  may  perhaps  be 
classed  as  rheumatic.  The  patient  was  a  boy  aged  three, 
previously  healthy  and  just  recovering  from  an  attack  of 
erythema  nodosum.  The  whole  thyroid  gland  was  enlarged 
and  caused  much  pain,  fever  and  dysphagia.  The  acute  phase 
of  the  disease  lasted  four  days  and  the  total .  duration  of  the 
enlargement  was  about  a  fortnight.  Much  relief  was  obtained 
by  the  application  of  a  single  leech  to  the  centre  of  the 
swelling. 

In  most  of  the  recorded  cases  of  rheumatic  thyroiditis,  the 
duration  of  the  acute  phase  appears  to  have  been  shorter, 
lasting  not  more  than  two  davs. 

Pyaemia  is  responsible  for  a  considerable  proportion  of 
cases.  +  A  case  of  abscess  of  the  thyroid  that  came  under  my 
notice  in  1886  in  the  post-mortem  room  of  St.  Bartholomew's 
Hospital  was  due  to  this  cause. 

The  patient  was  a  young  woman  aged  21,  who  died  of  pyaemia 
connected  with  necrosis  of  the  femur.  In  the  lower  part  of  the 
right  lobe  ^\'as  an  abscess  which  had,  however,  caused  no 
symptoms;  during  life  its  presence  had  not  been  suspected. 
Several  cases  of  thyroiditis  in  the  course  of  puerperal  fever  have 
been  recorded.* 

Malaria, §  Variola  and  Cholera*^  have  all  been  recorded 
as  causes  of  thyroid  inflammation. 

Traumatic  infl.am.miation  is  but  rarely  seen  in  the 
previously  healthy  thyroid.  Cases  in  which  it  has  been  caused 
by  attempts  at  strangulation,  rough  friction,  blows,  and  other 
forms  of  mechanical  injurv  have  been  cited  by  Walther'**  and 
others. 

*  Trans.  Clin.  &/:,  1888,  p.  67. 

f  H.  Lebert,  "  Die  Kranklieiten  der  Schilddriise  mid  ilire  Beliandluug,'' 
Breslau,  1862.     Guthrie  "  On  Gunshot  Wounds,''  1827,  p.  260. 

i  Laure.  Sen:  Med.  de  Lijun,  Jan.  1873.     Lebert.  oj).  cit.     Kohn.  »_[).  cit. 

§  Zesas.  "  Ueber  Strumitis  und  Thyreoditis  bei  IMalaria,"  QnitralbJ.  f.  Chir.. 
Xo.  30,  188.5. 

II  Liouville,  Mem.  dc  Sue  de  Biol.,  1870. 

f  Cruveilhier,  Ga:.  dc  Hop.  1849.  quoted  by  M.  D.  Simon,  Tliesis,  Paris,  1880, 

**  "  Xeue  Heila]"t  des  Kroj^fes  durch  Unterbindung  des  obern  Schilddrii^en 
Schlagadern,"'  S((l:l)ai-li,.  1817,  pp.  17-19,  quoted  by  Lebert. 


132  THE    THYROID    GLAND. 

Inflammation  and  suppm-ation  of  an  enlarged  (goitrous) 
thyroid  gland  is  often  seen  as  the  result  of  tapping,  injection, 
incision,  or  any  other  operation  which  has  been  performed 
without  sufficient  attention  to  asepsis. 

Krieg*  says  that  of  twenty-four  cases  of  inflamed  goitre 
observed  bv  Kocher,  in  no  less  than  nine  the  cause  was 
injection. 

One  of  the  chief  objections  to  the  employment  of  injection  as 
a  means  of  treating  goitre  is  that  it  may  set  up  a  dangerous 
amount  of  inflammation. 

Symptoms. — The  ordinary  signs  and  symptoms  of  inflamma- 
tion are  met  with  in  the  case  of  the  thyroid  gland,  as  they  are 
in  that  of  any  other  organ  of  the  body.  The  special  symptoms 
which  are  met  with  in  inflammation  of  this  organ  depend  upon 
its  close  connection  with  certain  important  structures  in  the 
neck.  Of  these  symptoms  the  most  important  are  dyspnoea,  dys- 
phagia and  pain  produced  by  pressure  upon,  or  involvement  of, 
the  cervical  and  brachial  plexuses.  Dyspnoea  is  produced  by 
the  direct  pressure  of  the  swollen  gland  upon  the  trachea,  and 
perhaps  to  a  certain  extent  also  by  the  involvement  of  the 
recurrent  nerves  in  the  inflannnation.  If  the  trachea  be  already 
narrowed  by  the  goitre,  the  extra  swelling  caused  by  the  inflam- 
mation may  lead  to  very  serious  respiratory  distress.  Dysphagia 
is  caused  either  by  direct  pressure  upon  the  oesophagus  or 
pharynx,  or  by  the  actual  involvement  of  these  structures  in 
the  inflammatory  process.  The  act  of  deglutition,  by  causing 
movement  of  the  inflamed  gland,  naturally  causes  pain.  Pain 
referred  to  the  peripheral  distribution  of  the  cervical  and 
brachial  nerves  is  a  common  symptom  of  thyroiditis,  and  affords 
an  important  means  of  diagnosis.  Other  forms  of  thyroid 
enlargement,  with  the  important  exception  of  malignant  disease, 
rarely  cause  severe  pain.  As  the  inflammatory  swelling  of  the 
gland  increases,  the  dyspnoea  becomes  more  and  more  severe, 
and  attacks  of  suffocation  occur  from  time  to  time.  Alteration 
in  the  voice  and  in  the  character  of  the  cough  also  occur.  The 
cough  gradually  assumes  the  peculiar  brassy  nature  so  charac- 
teristic of  tracheal  obstruction. 

*  Krieg.  Med.  Cor..  BL  d.  Wllrttei)ih.  Aerxfl.  Vet:  Stiittfj.,  1884,  liv.  p.  147. 


INFLAMMATION.  133 

The  pressure  symptoms  are  of  great  importance  since,  if  un- 
relieved, they  are  apt  to  result  in  fatal  suffocation.  Kohn  * 
says  that. inflammation  may  also  prove  fatal  by  extension  to  the 
mucous  membrane  of  the  trachea,  causing  this  to  swell,  and  so 
block  up  still  more  its  already  narrowed  lumen.  The  possibility 
of  the  rapid  occurrence  of  oedema  of  the  glottis  should  also  be 
borne  in  mind. 

If  suppuration  occur,  the  pus  is  exceedingly  likely  to  pene- 
trate the  capsule  of  the  gland,  and  to  make  its  way,  either  into 
the  cellular  tissue  of  the  neck  or  into  the  trachea  or  pharynx. 
If  it  pass  into  the  cellular  tissue  an  exceedingly  dangerous 
condition  supervenes.  The  dangers  of  a  diff'use  inflammation  of 
the  deeper  parts  of  the  neck  and  the  mediastinum  are  too  well 
known  to  need  further  description. 

Numerous  museum  specimens  illustrate  the  tendency  of  pus 
to  make  its  way  from  the  thyroid  gland  into  the  trachea  or 
pharynx.  The  sudden  discharge  of  a  quantity  of  pus  into 
either  of  these  cavities  generally  leads  to  the  immediate  suffbca- 
tion  of  the  patient,  and  the  liability  to  its  occurrence  should 
not  be  lost  sight  of. 

In  St.  Bartholomew's  Hospital  Museum  j  is  a  preparation 
Avhich  shows  a  large  thyroid  cyst  which  suppurated  and  burst 
into  the  pharynx. 

"  The  patient  was  an  elderly  woman  and  the  enlargement  of  the 
gland  had  long  existed.  The  cyst  at  first  contained  a  fluid  like 
serum,  which  when  withdrawn  spontaneously  coagulated.  After 
being  twice  emptied  the  walls  of  the  cyst  inflamed,  and  it  was 
rapidly  filled  with  pus  and  lymph  ;  its  wall  ulcerated  and  the  ulcera- 
tion extending  through  the  adjacent  part  of  the  pharynx,  the 
patient  was  suffocated  by  a  sudden  discharge  of  its  contents  and  the 
passage  of  some  of  them  into  the  larynx." 

It  will  be  seen  that  there  is  a  communication  between  the 
uppei-  part  of  the  cyst  and  the  pharynx,  near  the  arytenoid 
cartilage. 

Lebert  cites  a  curious  case  taken  from  Heidenreich's  work  on 
goitre.     A  young  man  suffered  for  six  months  with  what  Avas 

*   Op.  fit.  p.  21(5. 

t  No.  231-1:.  This  specimen  is  probably  from  Mr.  Vincent's  case  described  in 
Sir  James  Paoet's  "  Surgical  Pathology,"  1876,  p.  -tOl. 


134  THE   THYROID    GLAND. 

supposed  to  be  stricture  of  the  (esophagus  and  suppuration  of  the 
lungs.  It  was  known  that  he  had  a  goitre.  After  death  it  was 
found  that  both  oesophagus  and  knigs  Avere  quite  healthy.  All 
the  symptoms  were  due  to  the  goitre,  which,  besides  causing 
marked  pressure  upon  the  oesophagus,  had  suppurated  and  dis- 
charged pus  into  the  trachea,  a  short  distance  below  the  larynx. 
The  frequent  expectoration  of  this  pus  had  given  rise  to  the 
erroneous  diagnosis  of  suppuration  of  the  lungs. 

Perforation  into  the  trachea  usually  takes  place  in  the 
neighbourhood  of  the  first  or  second  ring. 

Penetration  of  the  pharynx  usually  occurs  near  the  up})er 
opening  of  the  larynx. 

Diagmosis. — Acute  inflammation  of  the  thyroid  gland  is 
likely  to  be  confounded  with  one  or  other  of  the  following 
affections. 

1.  Simple  acute  parenchymatous  enlargement  of  the 
gland,  especially  that  which  occurs  about  puberty  or  soon  after- 
wards. The  absence  of  fever,  pain,  and  tenderness  will,  however, 
generally  be  sufficient  for  the  establishment  of  a  correct 
diagnosis. 

2.  Inflammation  of  neighbouring  parts  may  easily  simulate 
thyroiditis.  Such  are  inflammations  of  the  cervical  lymphatic 
glands,  of  the  cellular  tissue  of  the  neck  and  of  the  larynx  itself. 
Careful  attention  to  the  exact  position  of  the  swelling,  and 
noticing  whether  or  not  it  moves  with  the  larynx,  will  probably 
enable  the  observer  to  distinguish  the  thyroid  affection  from 
the  others. 

An  interesting  case  has  been  recorded  by  Kohn*  in  which 
suppurative  perichondritis  of  the  larynx  was  accompanied  by  a 
tumour  so  closely  resembling  an  abscess  of  the  thyroid  gland 
as  to  be  mistaken  for  it.  A  fluctuating  tumour  as  large  as  a 
walnut  lay  exactly  in  the  situation  of  the  right  lobe  of  the 
thyroid,  and  being  attached  to  the  larynx  naturally  followed  its 
movements  during  deglutition. 

I  have  myself  seen  a  case  in  which  suppurative  perichondritis 
of  the  thyroid  cartilage  had  been  diagnosed  as  a  tumour  of  the 
thyroid  gland. 

*   021.  fit.  p.  244. 


INFLAMMATIOX.  135 

3.  Sudden  extravasation  of  blood  into  a  cystic  thyroid- 
gland  may  also  closely  simulate  acute  inflammation. 

4.  Malignant  disease  is  often  mistaken  for  inflammation, 
especially  ^vhen  it  occurs  in  the  form  of  a  soft  rapidly  growing 
tumour.  The  diagnosis  is  especially  difficult,  when,  as  often 
happens,  a  malignant  tumour  penetrates  the  air  or  food  passages 
and  thus  becomes  the  seat  of  septic  inflammation. 

Treatment. — In  the  earlv  stages,  before  suppuration  has 
occurred,  the  treatment  should,  consist  in  the  administration  of 
a  purgative  and  the  local  application  of  hot  fomentations.  If 
the  inflammation  be  due  to  a  specific  cause  such  as  rheumatism 
or  syphilis,  specific  remedies  such  as  salicylate  of  soda  and 
iodide  of  potassium  must  of  course  be  administered.  A  careful 
watch  should  be  kept  upon  the  breathing,  and  if  dyspnoea 
threaten  to  become  severe,  the  surgeon  must  be  prepared  to 
operate  promptly.  The  danger  of  suffocation  should  not  be  lost 
sight  of. 

If  the  case  has  gone  on  to  suppuration,  the  pus  should  be 
evacuated  as  soon  as  possible.  Some  have  recommended  aspira- 
tion and  the  injection  of  carbolic  acid  or  other  antiseptic,  but 
direct  incision  seems  to  be  preferable.  If  the  suppuration  occni" 
in  a  previously  healthy  gland  or  in  one  that  is  the  seat  of  a 
general  parenchymatous  enlargement,  the  surgeon  should  usually 
be  content  with  simple  evacuation  of  the  pus.  If,  however, 
suppuration  take  place  within  a  cvstic  or  other  encapsuled 
tumour,  as  is  frequently  the  case,  then  it  is  generally  best  to 
perform  enucleation  of  the  cyst.  Kocher  speaks  of  inflammation 
as  favouring  in  some  cases  the  operation  of  enucleation,  since 
thereby  the  tumour  is  loosened  from  its  connections.  In  other 
cases,  however,  in  which  there  has  been  long-continued  inflam- 
mation, the  operation  may  be  rendered  yery  difficult,  and  when 
there  is  much  fixity  of  the  cyst  it  may  even  be  best  not  to 
attempt  its  removal  but  to  be  content  with  incision  and  drain- 
age. 

In  all  cases  of  operation  for  acute  abscess  the  wound  should 
be  drained.  The  necessity  for  an  early  operation  in  cases  of 
abscess  of  the  th\Toid  gland  is  obvious  when  we  consider  hew 
great  a  tendency  there  is  for  the  pus  to  make  its  way  into  the 


136  THE    THYROID    GLAND. 

deeper  structures  of  the  neck  and  thus  to  set  up  most  dangerous 
complications. 

The  treatment  of  thyroid  fistulae.  the  result  of  inflammation, 
must  be  conducted  upon  general  principles.  The  fistula  must 
be  kept  as  clean  as  possible  by  washing  and  free  drainage.  If 
there  be  much  surrounding  inflammation,  wet  antiseptic  com- 
presses frequently  changed  form  the  best  application  at  first. 
The  mouth  of  the  fistula  must  be  opened  as  much  as  possible,  so 
as  to  convert  the  fistula  into  an  open  wound  and  allow  it  to  heal 
up  from  the  bottom.  The  situation  of  the  fistula,  in  close 
proximity  to  large  blood-vessels  and  other  important  structures, 
often  renders  a  free  laying  open  of  the  pai'ts  quite  impossible. 
The  surgeon  must  then  be  content  with  laving  open  the  super- 
ficial part  and  draining  the  deeper  regions.  If  the  fistula  have 
followed  an  operation  in  which  silk  ligatures  have  been  em- 
ployed, it  will  often  not  heal  until  these  have  been  removed. 
The  casting  off"  of  ligatures  from  an  operation  wound  in  this 
region  is  a  most  tedious  process,  often  occupying  many  months. 
If  the  fistula  be  connected  with  a  hard  fibrous  or  calcareous 
goitre,  its  walls  may  be  so  rigid  that  they  cannot  come 
together ;  the  fistula  will  then  be  a  permanent  one  unless  the 
tumour  be  removed. 

Such  fistulae  are  by  no  means  uncommon  after  the  injection  of 
tough  walled  cysts  and  old  adenomata.  Fig.  86  shows  a  case  of 
this  kind  in  which  the  fistula  had  existed  for  many  years. 

The  following  case  came  under  mv  care  some  vears  ago  : 

Kate  C,  aged  85,  domestic  servant,  was  admitted  to  the  Royal 
Free  Hospital  in  Nov.  1891;,  on  account  of  a  sinus  in  the  neck, 
painful  swellings  of  the  joints  and  other  symptoms  of  septic  absorp- 
tion. Eleven  months  previously,  at  another  hospital,  a  right-sided 
goitre  had  been  injected  and  incised.  Much  suppm*ation  had 
followed  the  operation  and  a  sinus  had  been  present  ever  since. 
When  the  discharge  from  it  was  abundant  the  patient  was  fairly 
well.  When  the  sinus,  however,  became  blocked,  as  it  did  every 
few  weeks,  and  the  discharge  became  pent  up,  the  patient  had  high 
temperatures  and  suffered  severely  from  septic  absorption.  She  was 
consequently  unable  to  follow  her  occupation.  In  the  right  side  of 
the  neck  was  a  thyroid  tumour  as  large  as  a  goose's  egg.  A  sinus 
led  directly  into  its  intei'ior  and  was  about  two  inches  long.       Foul 


INFLAMMATION.  137 

pus  oozed  continually  from  the  opening.      The  tumour  was  a  good 
deal  fixed  by  suiTOunding  inflammation. 

For  a  few  weeks  the  sinus  was  washed  out  and  cleansed  as  much 
as  possible.  On  Dec.  8,  1891,  the  whole  of  the  right  lobe  was 
extirpated  in  the  usual  manner.  Great  care  was  necessary  in  the 
operation  to  prevent  contamination  of  the  extensive  wound  with 
the  septic  contents  of  the  sinus.  The  tuinour  and  surrounding 
parts  were  so  matted  together  by  old  inflammation  that  the  opera- 
tion was  tedious  and  difficult.  The  wound  was  drained  and  the 
patient  made  a  rapid  and  excellent  recovery.  The  temperature 
never  rose  above  ^9%  and  the  wound  healed  by  primary  union. 
The  patient  never  had  any  further  trouble,  and  when  last  heard  of, 
eight  years  after  the  operation,  was  in  excellent  health.  The 
tumour  (now  in  thej  Royal  Free  Hospital  Museum,  Ko.  xxii,  ,'>) 
shows  a  solid  adenoma  with  much  surrounding  fibrous  tissue  and  an 
abscess  cavity  in  the  centre. 

Still  more  serious  is  the  condition  of  affairs  when  a  thyroid 
fistula  opens  on  to  a  mucous  surface,  the  trachea  or  oesophagus. 

In  the  Museum  of  Charing  Cross  Hospital  is  a  specimen  *  of 
a  large  solid  thyroid  adenoma  which  was  removed  by  Mr.  John 
H.  Morgan  on  account  of  a  fistula  which  opened  both  externally 
and  also  internally  into  the  oesophagus. 

The  patient  was  a  woman  aged  46",  whose  goitre  had  been 
injected  four  years  previously  at  another  hospital.  After  other 
methods  had  failed  to  cure  the  fistula,  the  whole  tumour  was 
removed  by  operation.  The  opening  into  the  oesophagus  which  w«s 
just  below  the  cricoid  cartilage  was  closed  with  fine  silk  sutures, 
and  the  wound  drained.  The  patient  made  an  excellent,  although 
somewhat  tedious  recovery.! 


Primary  Chronic  Inflammation. 

Under  this  name  may  be  described  a  remarkable  and  somewhat 
rare  affection  which  seems  to  have  attracted  but  little  attention 
in  this  country.  It  is  characterised  by  the  development  in  the 
thyroid  gland  of  a  tumour  of  exceeding  density  and  hardness, 
which  shows  a  remarkable  tendency  to  become  adherent  to,  and 

*  No.  877a. 

t  A  full  account  of  this  case  has  been  published  by  Mr.  Morgan  in  the 
Illustrated  Med.  News  for  June  2i).  1889. 


138  THE   THYROID    GLAND. 

even  to  surround  and  infiltrate,  neighbouring  structures.  Various 
names  have  been  given  to  the  affection,  the  pathology  of  which 
is  still  somewhat  obscure. 

Tailhefer,*  in  an  excellent  paper  upon  the  subject,  uses  the 
name  "  primary  canceriform  chronic  inflammation.*''  Bowlbyf  has 
published  a  typical  case  under  the  name  of  "  infiltrating 
fibroma,"  and  seems  to  think  that  the  disease  is  allied  to 
sarcoma.  There  can,  however,  be  but  little  doubt  that  chronic 
inflammation  is  the  term  that  is  most  correct.  The  remarkable 
similarity  which  exists,  both  clinically  and  pathologically, 
between  this  disease  and  some  of  the  harder  forms  of  malignant 
disease  is  very  striking.  Indeed  almost  every  case  hitherto 
described  has  been  diagnosed  at  first  as  malignant  disease.  To 
Riedel  i  of  Jena  we  are  indebted  for  drawing  attention  to  the 
true  nature  of  the  disease  and  in  the  publication  of  two  cases 
that  came  under  his  care. 

I  have  myself  seen  three  cases.  One  of  these  was  the  case 
published  by  ]Mr.  Bowlby,  which  was  under  the  care  of  Sir 
Thomas  Smith.  The  other  two  were  under  my  own  care  at  the 
Royal  Free  Hospital. 

The  disease  occurs  both  in  men  and  in  women.  It  appears  to 
be  most  common  in  middle  age  but  cases  in  childhood  have  been 
recorded.  A  swelling  is  noticed  in  one  or  other,  or  both,  lobes, 
of  the  gland.  It  grows  steadily  and  painlessly,  and  when  it 
reaches  the  exterior  of  the  gland  it  becomes  firmly  fixed  to  the 
trachea,  carotid  vessels,  I'ecurrent  nerves,  and  other  structures. 
It  exerts  pressure  upon  all  the  structures  and  causes  dyspnoea, 
dysphagia,  dysphonia,  and  obliteration  of  the  carotid  pulse.  If 
untreated  it  gradually  compresses  the  trachea  more  and  more 
and  causes  death  bv  suffocation.  The  swelling  does  not  usually 
attain  any  great  size,  the  lateral  lobe  of  the  thyroid  being  seldom 
larger  than  a  goose's  egg. 

The  extreme  hardness  of  the   tumour  has  been   likened   by 

*  "  luliainmation  cJiroiiique  ijrimitive  '  canceriforme '  de  la  glande  thyro'idi:",'' 
by  E.  Tailhefer  in  Brr.  de  Chir.,  Paris,  March  10,  1898,  vol.  xviii.  p.  -li-^. 

f  "  Infiltrating  fibroma  (.'  sarcoma)  of  the  th^Toid  gland,''  Tranx.  Path.  Soc 
1885,  vol.  XXX vi.  p.  120. 

X  "  Die  chronische  znr  Bildung  eisenharter  Tumoren  fiihrende  Entziindung 
der  Schilddriise,"  YerhnndJ.  d.  JJeutxch.  GexeUtwh.  f.  Chir.,  Berlin,  18'J(),  i. 
p.  101. 


INFLAMMATION.  139 

various  observers  to  that  of  wood,  iron  or  stone.  It  is  quite 
distinct  from  the  ordinary  fibroid  degeneration  so  commonly 
seen  in  parenchymatous  and  adenomatous  goitres.  The  latter 
progresses  extremely  slowly  and  does  not  cause  infiltration  of,  or 
adhesion  to,  surrounding  parts. 

The  following  are  the  three  cases  which  have  come  under  my 
own  notice  : 

Mrs.  Eliza  D ,  cEt.  42^  was  admitted  into  St.   Bartholomew's 

Hospital  on  Nov.  28^  1883,  under  the  care  of  Sir  Thomas  Smith. 
Three  years  previously  she  had  first  noticed  a  swelling  of  the  lower 
part  of  the  neck.  During  the  next  year  this  swelling  gradually 
inci'eased  and  her  breathing  then  became  affected.  At  this  period 
she  consulted  a  doctor  who  found  that  the  thyroid  gland  was  "  very 
slightly  enlarged,  firm,  and  not  at  all  painful."*  A  year  later  it  was 
found  that  the  thyroid  was  apparently  incorporated  with  the 
trachea,  the  place  of  the  gland  being  taken  by  a  very  hard,  painless 
growth.  She  was  treated  with  iodide  of  potash  and  biniodide  of 
mercury  ointment,  but  did  not  improve.  On  the  contrary  her 
breathing  gradually  became  worse  and  worse,  and  she  was  liable  to 
fits  of  coughing  brought  on  by  active  movement.  "  The  stony 
hardness  of  the  growth  was  by  this  time  very  remarkable  and  was 
of  such  a  nature  as  to  suggest  the  presence  of  cartilage  or  bone. 
In  April  1883,  the  patient  was  seen  by  Sir  Felix  Semon,  who 
expressed  the  opinion  that  the  disease  was  of  a  malignant  nature. 
He  found  the  trachea  much  narrowed,  the  left  abductor  paralysed, 
and  the  left  vocal  cord  completely  fixed  in  the  middle  line.  "  The 
dyspnoea  continued  to  increase,  and  at  times  suffocation  seemed 
imminent.  Dysphagia  and  weakness  of  voice  were  now  noticed. 
"  On  admission  to  the  hospital  dyspnoea  was  very  urgent.  The  front 
of  the  neck  was  occupied  by  an  excessively  hard  mass,  which  enve- 
loped the  whole  of  the  tissues  from  the  level  of  the  hyoid  bone 
downwards  to  the  episternal  notch,  and  in  which  it  was  not  possible 
to  recognise  any  of  the  normal  structures  of  this  region.  Free 
division  of  the  isthmus  of  the  thyroid  failing  to  give  any  relief, 
tracheotomy  was  performed.  Some  temporary  relief  was  afforded, 
but  the  dyspnoea  returned  and  the  patient  died  on  Dec.  4."  The 
post-mortem  examination  was  made  by  Mr.  Bowlby  who  has  given 
the  following  description  :  "  The  viscera  generally  were  healthy. 
There  were  no  signs  whatever  of  secondary  growth  and  none  of 
glandular  affection  throughout  the  body.     The  thyroid  gland  and 

*  The  description  of  this  case  is  largeh'  from  the  account  given   hy  Mr. 
Bowlbv  in  the  Path.  Sue.  Trunx.,  vol.  xxxvi. 


140  THE   THYROID    GLAND. 

adjacent  parts  are  occupied  by  a  large  new  growth.  The  tumour 
is  extremely  hard,  and  of  a  similar  shape  to  the  gland  in  which  it 
grows,  being  composed  of  two  latei*al  lobes  of  equal  size,  joined  by 
an  isthmus.  Its  cut  surface  is  fibrous.  Each  lobe  reaches  the  level 
of  the  hyoid  bone  above  and  of  the  bifurcation  of  the  trachea  below  ; 
they  are  joined  by  a  bi-oad  isthmus  reaching  from  the  cricoid  carti- 
lage over  the  upper  half  of  the  trachea.  Above,  the  lobes  present  a 
rounded  outline,  are  quite  separate  from  each  other  and  their  limits 
are  clearly  marked.  Behind,  beloAv  and  laterally,  the  limits  of  the 
growth  are  quite  undefined,  the  surrounding  parts  being  infiltrated 
by  the  tumour  and  not  simply  pushed  aside.  Thus  the  common 
carotid  artery,  the  external  and  internal  carotids,  the  internal 
jugular  vein, the  pneumogastric,  recurrent  laryngeal  and  sympathetic 
nerves  are  on  each  side  entirely  included  in  the  tumour.  The 
depressor  muscles  of  the  hyoid  bone  are  infilti'ated  and  fixed  ;  the 
oesophagus  is  infiltrated  and  so  compressed  an  inch  and  a  half  below 
the  cricoid  cartilage,  that  the  tip  of  the  little  finger  can  barely  be 
passed.  The  trachea  has  been  compressed  both  laterally  and  in 
front ;  in  the  latter  situation  by  the  isthmus  of  the  tumour  (which 
has  been  divided),  while  its  lower  portion,,  which  in  life  occupied  the 
thorax  and  root  of  the  neck,  is  infiltrated  with  new  growth  on  each 
side,  and  so  narrowed  by  lateral  compression  that  the  little  finger 
cannot  be  passed.  The  aorta  and  all  its  branches,  the  innominate 
veins,  with  the  superior  vena  cava  and  the  pulmonary  artery,  are  all 
incorporated  in  the  tumour  to  a  greater  or  less  extent,  but  although 
the  calibre  of  these  vessels  is  more  or  less  diminished  by  pressure, 
in  none  of  them  is  there  any  ulceration  or  clotting  of  blood.  The 
apex  of  the  left  lung  is  closely  adherent  to,  and  not  separable  from, 
the  lowest  portion  of  the  growth.  The  bifurcation  of  the  trachea, 
Avith  both  bronchi,  is  adherent  to  the  tumour,  as  ai*e  also  the 
bronchial  Ijaiiphatic  glands.  Neither  in  the  neck  nor  in  the  thorax 
w^ere  these  latter  at  all  enlarged  or  otherwise  altered.  I  made  a 
very  careful  examination  of  different  parts  of  the  tumour,  sections 
being  taken  both  from  the  centre  and  the  periphery.  The  structure 
was  entirely  fibrous  without  the  least  appearance  of  either  alveola- 
tion  or  of  epithelial  cells." 

The  following  case  was  under  my  own  care  at  the  Royal  Free 
Hospital  and  differs  from  the  others  in  that  spontaneous  ulcera- 
tion of  the  skin  occurred,  as  may  be  seen  in  the  accompanying 
photograph  (Fig.  59). 

Mary  S ,  a?/.  63,  widow,  was   admitted  into  the    Royal  Free 

Hospital  on  Jan.  20,  1899,  on  account  of  dyspnoea  and  an  enlarged 


INFLAMMATION. 


141 


thyroid  gland.  She  had  had  for  many  years  a  swelling  in  the  neck 
■which  had  given  her  no  trouble  until  about  fifteen  months  before 
admission.  At  this  time  the  swelling  on  tlie  right  side  became 
lai-ger  and  eventually  broke  through  the  skin.  An  indolent  sinus 
had  been  present  ever  since.  In  the  last  two  months  she  had  had 
much  severe  dyspnoea,  especially  at  night.  She  had  also  lost  flesh 
in  the  last  few  weeks. 

On  admission  she  was  found   to  be  pale  and  thin.      She  breathed 


Fig.  59. — Primary  Ch.ronic  Infl.amm.ation  ol  tlie  Thyroid, 
leading  to  spouMiifons  ulceration  of  the  skin.  (.Tlie  darkness  of 
the  skin  is  dtie  to  a  photoiiTapliie  error.") 

with  much  difficulty  and  stridor,  and  had  to  lie  in  a  semi-recumbent 
position,  as  she  could  not  breath  while  lying  down.  Temp.  9^'  • 
Pulse  120,  Resp.  36.  There  was  also  a  good  deal  of  bronchitis. 
There  was  little  or  no  dysphagia. 

The  right  lobe  of  the  thyroid  formed  a  hard  irregular  mass  about 
as  large  as  a  goose's  egg.  The  skin  over  it  was  adherent ;  in  the 
middle  of  the  adherent  area  was  a  shallow,  narrow,  ulcerated  surface 
two  inches  long  bv  half  an  inch  wide  and  extending  nearly  half  an 


[42  THE    THYROID    GLAND. 

inch  into  the  substance  of  the  gland.  On  the  left  side  of  the  neck 
was  a  similar  but  somewhat  smaller  swelHng  not  nearly  so  hai'd  ; 
the  skin  over  this  was  not  ulcerated.  The  whole  swelling  moved 
Avith  the  larynx,  but  not  very  freely.  With  the  laryngoscope  great 
lateral  flattening  of  the  trachea  was  seen,  the  walls  were  about  ^ 
inch  wide  at  the  narrowest  part.     The  vocal  cords  moved  naturally. 

The  diagnosis  of  the  case  was  not  clear  ;  the  swelling  was 
believed  to  be  chronic  inflammation  of  a  peculiar  nature,  possibly 
tuberculous,  but  the  idea  of  malignancy  could  not  be  altogether 
excluded.  It  was  clear  that,  owing  to  the  fixity  of  the  growth,  no 
removal  was  possible.  It  was  thought  that  tracheotomy  would  soon 
be  required.  The  case  was  seen  by  my  colleague,  Mr.  Battle, 
who  agreed  both  with  the  diagnosis  of  probable  chronic  inflamma- 
tion and  also  with  the  impossibility  of  removing  the  tumour  by 
operation. 

On  June  23,  the  patient  having  had  several  attacks  of  severe 
dyspnoea,  tracheotomy  was  performed  without  any  general 
anaesthetic.  The  operation  which  lasted  ten  minutes  was  diflicult 
owing  to  the  hardness  and  nodularity  of  the  gland,  Avhich  made  it 
difiicult  to  distinguish  the  trachea  from  neighbouring  parts.  A  long 
Koenig's  canula  was  inserted.  The  patient's  breathing  was  easier 
after  the  operation.  On  the  following  day  the  tube  was  removed 
for  cleansing  and  then  replaced.  The  patient's  temperature  which 
had  been  100"  before  the  operation  Avas  never  afterAvards  quite 
normal  :  her  pulse  Avas  generally  between  120  and  l60.  The 
patient  died  six  days  after  the  operation  Avith  symptoms  of  septic 
bronchitis. 

The  post  mortem  showed  a  bilateral  parenchymatous  goitre  of 
moderate  size  and  Avith  a  fcAv  cysts  evidently  of  long  duration.  The 
lower  half  approximately  of  the  right  lobe  Avas  occupied  by  a 
densely  hard,  yellowish-white,  ill-defined  mass,  Avhich  Avas  firmlj- 
adherent  to  the  trachea  for  about  an  inch  and  a  half,  and  also  to  the 
left  carotid  vessels.  In  the  corresponding  part  of  the  left  lobe  is  a 
similar,  but  much  smaller  mass  of  the  same  nature.  The  resem- 
blance to  a  scirrhous  carcinoma  Avas  Aery  great,  but  careful  micro- 
scopical examination  shoAved  nothing  but  dense  fibrous  tissue  Avith 
remains  of  thyroid  tissue  here  and  there.  There  Avas  no  trace  of 
malignancy  anyAvhere.^ 

The  third  case  illustrates  a  much  earlier  .stage  of  what  I 
belieA'e  to  be  the  same  disease,  but  as  the  dense  fibrous  growth 
had  in  this  case  not  reached  the  capsule  of  the  gland,  there  Avere 

*  The  specimen  is  now  in  the  Koyal  Free  Hospital  Miiseuni,  Xo.  xxii.  .">. 


INFLAMMATIOX.  143 

no  adhesions  to  surrounding  parts  and  complete  removal  of  the 
affected  lobe  was  possible. 

Mrs.  Charlotte  G ,*  cet.  40^  was  admitted  under  my  care  into 

the  Royal  Free  Hospital,  on  account  of  a  swelling  of  the  right  lobe 
of  the  thyroid. 

Five  weeks  before  admission  she  had  first  noticed  a  lump  in  this 
region ;  it  had  steadily  increased  in  size.  She  complained  of 
occasional  shooting  pains  in  the  lump,  and  also  of  a  slight 
"■'choking"  feeling.  Otherwise  she  appeared  to  be  in  good  health. 
The  extreme  hardness  of  the  lump,  its  slight  irregularity  together 
with  the  history  of  a  rapid  growth  and  sharp  pains  led  to  a  strong 
suspicion  of  malignant  disease  in  an  earlv  stage. 

Accordingly  on  May  13,  1898,  extirpation  of  the  right  lobe  was 
performed.  The  operation  presented  no  unusual  difficulty  of 
any  kind  ;  the  subsequent  course  of  the  case  was  quite  ordinary  : 
the  Avound  was  drained  for  twenty-four  hours  and  then  healed 
throughout  by  primary'  union.  The  tempei-ature  never  reached 
100°  at  any  time.  The  patient  left  the  hospital  eleven  days  after 
the  operation  quite  well  in  every  respect.  She  came  to  show  her- 
self from  time  to  time  and  remained  perfectly  well.  She  was  last 
seen  about  two  vears  after  the  operation. 

The  tumour  that  had  been  removed  Avas  as  large  as  a  hens  ^gg. 
The  peripheral  portion  to  a  depth  of  about  a  quarter  of  an  inch 
consisted  of  normal  dark  coloured  thyroid  tissue.  All  the  central 
part  however  consisted  of  a  somewhat  ill-defined  mass  of  connective 
tissue,  which  on  section  was  found  to  be  extremely  hard,  white, 
shiny  and  glistening. 

Microscopically  it  consisted  of  dense  inflammatory  tissue  with 
remains  of  thyroid  tissue  between  the  bundles  of  fibrous  tissue. 

Riedel  t  has  recorded  the  following  cases  : 

A  man  aged  42  had  noticed  for  about  six  months  a  swelling  of  the 
thjToid  gland  which  caused  considerable  dyspnoea.  The  tumour 
was  bilateral,  not  very  large,  but  extremely  hard  and  fixed.  It 
was  believed  to  be  malignant  and  on  November  30,  1883,  an 
attempt  was  made  to  remove  it  by  operation.  After  the  gland  had 
been  exposed  however,  it  was  found  to  be  intimately  united  on 
both  sides  with  the  carotid  artery  and  jugular  vein.  The  operation 
for  its  removal  was  therefore  abandoned,  and  Riedel  contented 
himself  with  cutting  away  a  piece  of  growth  as  large  as  a  walnut. 

*  See  Appendix,  Case  .56.  p.  346.  j   Op.  cit. 


144  THK    THYROID    (JLANl). 

The  wound  healed  without  any  trouble  and  the  jiatient's  breathing 
improved  so  much  that  at  the  end  of  six  months  his  dyspnoea  had 
entirely  disappeared,  he  seemed  quite  well  and  was  able  to  do 
his  ordinary  work.  Fifteen  months  after  the  operation  this  patient 
died  of  nephritis  and  apoplexy.  There  was  no  post  mortem.  The 
])ortion  of  tumour  that  had  been  removed  was  examined  micro- 
scopicallv.  There  Avas  no  sign  of  sarcoma  or  carcinoma.  The 
tumour  was  composed  of  chronic  inflammatory  tissue.  There  was 
no  evidence  of  tubercle  or  syphilis. 

Twelve  years  later  Riedel  met  with  the  following  case  : 

A  healthy  looking  woman  aged  23  had  noticed  that  for  a  period 
of  one  year  her  neck  had  been  swollen.  In  the  last  two  months 
the  swelling  had  increased  tolerably  rapidly.  The  patient  had 
much  dyspnoea  on  exertion.  The  thyroid  gland  was  enlarged  on 
the  right  side  to  the  size  of  a  hen's  egg,  on  the  left  to  that 
of  a  small  apple.  The  tumour  was  remarkably  hard  and  fixed.  As 
in  the  preceding  case  the  operation  for  removal  of  the  tumour  had 
to  be  abandoned  on  account  of  the  extensive  adhesions  of  the 
tumour  with  the  blood  vessels  and  recurrent  nerves.  Micro- 
scopical examination  of  a  portion  of  the  tumour  showed  chronic 
inflammatorj'  tissue.  The  patient's  breathing  improved  after  the 
operation,  she  was  able  to  get  about  and  was  apparently  nearly 
well.  About  two  months  after  the  operation  she  was  suddenly 
seized  with  symptoms  of  embolism  and  died  in  a  few  minutes. 
There  was  no  post-mortem  examination. 

The  case  that  formed  the  subject  of  Tailhefer's  first  paper  * 
was  under  the  care  of  ]\1.  Jeannel  of  Toulouse.  Tailhefer  him- 
self assisted  at  the  operation. 

The  patient  Avas  a  man  of  thirty  who  for  three  months  had 
noticed  aphonia  and  a  swelling  of  the  neck.  The  left  lobe  of  the 
thyroid  was  found  to  be  occupied  by  a  '•  very  hard,  ill-defined,  fixed 
and  painless  tumour,  not  involving  the  skin."  The  tumour  was 
thought  to  be  malignant  and  its  removal  was  attempted.  The 
tumour  was  found,  however,  to  involve  the  carotid  sheath  and 
neighbouring  parts  so  extensively  that  the  operation  had  to  be 
abandoned,  a  small  piece  only  of  the  growth  being  removed.  The 
operation  was  followed  by  secondary  haemorrhage  from  the  carotid, 
necessitating  ligature  of  that  vessel.  Suppuration  and  hemiplegia 
followed    but     the    patient     eventually    recovered.        Histological 

*  "  Vuriete  tres  rare  de  tliyro'i<litp  chroni<iue,"  -l.vi.w.  Fn/nr.  dr  r/iir.  Fnu-. 
rrvh.,  Paris,  IS'.tf.,  x.  p.  328. 


INFLAMMATION.  145 

examination  showed  the  tumours  to  be  composed  of  '■  an  abund- 
ance of  fibrous  tissue  with  a  few  collections  of  inflammatory  cells. 
but  no  thyroid  vesicles." 

Tailhefer  in  his  second  communication*  on  this  subject 
mentions  also  three  other  cases  of  a  similar  nature  communicated 
privately  to  him  by  Riedel  and  Cordua.  All  these  were 
diagnosed  before  operation  as  sarcoma.  All  underwent  opera- 
tion which  in  one  case  at  least  \vas  incomplete.  Nevertheless 
the  patients  recovered  and  were  well  at  periods  varying  from 
some  months  to  several  rears  after  the  operation. 

The  cause  of  this  curious  disease  appears  to  be  quite  un- 
known. 

Treatment  by  drugs  such  as  iodide  of  potassium  seems  to  be 
useless.  There  can  be  no  doubt  that  if  seen  at  a  sufficiently 
early  period,  before  the  disease  has  penetrated  the  capsule, 
extirpation  of  the  diseased  lobe  of  the  gland  is  the  best  treat- 
ment. The  surgeon  must  be  prepared,  however,  to  meet  with 
serious  difficulties  in  the  course  of  the  operation,  owing  to  adhe- 
sions, and  must  be  ready  to  abandon  the  operation  if  these 
difficulties  prove  to  be  insurmountable. 

Partial  removal  of  the  enlargement  has  had  in  some  cases 
.such  a  beneficial  etfect  upon  the  course  of  the  disease  that  even 
incomplete  attempts  at  removal  appear  to  be  quite  justifiable. 

As  Riedel  says,  "  Operation  should  be  undertaken,  but  the 
operator  should  know  when  to  leave  offi"  Riedel  himself  in  his 
first  case  strove  for  two  hours  to  remove  the  tumour.  Most 
surgeons  will  agree  with  him  in  thinking  this  time  excessive.  He 
remarks  that  in  his  second  case,  in  which  the  condition  of  affairs 
was  more  readily  recognised,  he  abandoned  the  operation  at  a 
much  earlier  period  before  the  main  vessels  had  been  damaged. 

Tracheotomy  in  advanced  cases  may  become  necessary  but  is 
apt  to  be  both  difficult  and  dangerous.  Unless  the  dyspnoea  is 
extremely  m'gent,  a  partial  removal  followed  bv  primary  union 
would  appear  to  be  a  better  operation  than  tracheotomy  with  its 
attendant  risk  of  sepsis. 

*  "  Inflammation  chronique  primitive  canceriforme  de  la  glande  tliyroide." 
Bev.  de  Chir.,  Paris,  1898,  xviii.  Xo.  3.  p.  224. 


CHAPTER   IX. 

TUBERCLE   AND   SYPHILIS. 

Tubercle  :  Miliary — r.<iuilly  secondary — Caseating — Earity  of — Extir- 
pation of  tuberculous  goitre.  Syphilis  :  fi-equeuth^  atiects  thyroid  in 
form  of  slight  general  enlargement  —  Gummata  rare  — -  Congenital 
s}'philis. 

Tubercle. — Tubercle  is  not  uncommon  in  the  thyroid  gland  ; 
but  it  occurs  almost  exclusively  in  the  form  of  miliary  tubercle, 
and  usually  onlv  as  a  part  of  a  general  acute  tuberculosis. 
Consequently  it  seldom  gives  rise  to  any  symptoms  during  life, 
and  is  of  very  little  practical  importance.  Chiari  in  one  hundred 
post  mortems  upon  tuberculous  patients,  found  tubercle  of  the- 
thyroid  seven  times,  in  the  form  either  of  acute  miliary  tubercle 
or  chronic  infiltration.* 

Museum  specimens  are  rare.  In  the  Royal  College  of  Surgeons- 
is  a  specimen  t  of  a  thyroid  gland  containing  a  very  small 
tubercle.  It  Avas  obtained  by  myself  from  the  body  of  a  child 
aged  four,  who  had  died  in  St.  Bartholomew''s  Hospital  of  acute 
general  tuberculosis.  In  1890  Mr.  Bidwell  showed  at  the 
Hunterian  Society  a  similar  specimen,  taken  from  a  child  five 
and  a  half  years  of  age,  who  had  died  of  acute  general  tuber- 
culosis. In  the  centre  of  the  right  lobe  v/as  a  caseating  tubercle 
of  the  size  of  a  large  pin's  head.  I  have  seen  a  similar  specimen 
in  the  museum  of  the  Pathological  Institute  at  Berlin,  and  have 
also  seen  in  the  Pathological  Museum  at  Prague  a  specimen  :|:  of 
a  thyroid  gland  infiltrated  with  tubercle. 

In  St.  George's  Hospital  Museum  §  is  a  specimen  of  a  smalt 

*  "  Ueber  Tuberculose  der  Schilddrlise,"  Oestei-r.  Med.  JalirhA)i\  in  Virchow 
and  Hirsch's  "  Jalu-esbericht,"  1878,  A-ol.  i.  p.  277. 

t  No.  2906P.  t  Xo.  3973. 

§  No.  24.  See  also  a  description  of  this  case  by  Dr.  Eolleston  in  the  Trans.. 
Path.  Sor:,  1897,  vol.  xMii.  p.  197. 


TUBERCLE    AND    SYPHILIS.  147 

tuberculous  abscess  of  the  thyroid.  It  had  burst  into  the 
oesophagus.  It  had  not  been  detected  during  life.  The  patient 
was  a  woman  aged  twenty-three,  who  died  of  paraplegia  following 
caries  of  the  spine.  Dr.  Rolleston,  in  the  paper  mentioned 
below,  alludes  to  other  cases  of  miliary  tubercle  of  the  thvroid 
observed  by  Dr.  Perry,  Dr.  Voelcker,  and  himself. 

Tuberculosis  of  the  thyroid  occasionally  occurs  in  the  form  of 
larger  caseating  masses.  Such  cases  have  never  come  under  my 
notice. 

In  April  1873  Dr.  Quinlan  *  showed  at  a  meeting  of  the 
Pathological  Society  of  Dublin  a  much  enlarged  thvroid.  It 
was  taken  after  death  from  a  man  who  died  of  "  great  weakness 
and  loss  of  speech."  The  tumour  was  said  to  possess  the 
"  microscopical  characters  of  tubercle."" 

Dr.  P.  Bruns,  of  Ti'ibingen,  has  collected  several  cases  f  of 
tubercle  of  the  thyroid.  In  some  of  these  the  disease  occurred 
in  the  form  of  caseous  masses  of  considerable  size. 

One  of  these  cases  occurred  in  his  own  practice,  and  is,  so  far 
as  I  know,  the  only  example  of  a  tuberculous  thyroid  gland 
attaining  sufficiently  large  dimensions  to  cause  pressure  symp- 
toms, and  to  require  an  operation  for  its  removal.  It  is  probably 
also  the  only  case  hitherto  recorded  of  primary  tuberculous 
disease  of  the  thyroid. 

The  following  is  an  abstract  of  this  verv  interestino-  case  : 

F.  E ,  cet.  41^  a  widow,  had  had  from  childhood  a  small,  soft 

goitre  which  gradually  increased  in  size,  but  caused  no  other  trouble 
until  six  months  before  admission  to  hospital.  During  this  latter 
period  it  had  grown  rapidly  and  caused  much  pain  and  dyspnoea. 

The  patient's  general  health  appeared  to  be  good  and  she  had  no 
cough  or  expectoration  or  any  other  sign  or  symptom  of  pulmonary 
tuberculosis.  The  thyroid  gland  was  enlarged  in  all  parts  ;  the 
right  lobe  formed  a  swelling  as  large  as  a  child's  fist  and  extended 
outwards  under  the  sterno-mastoid  and  downwards  under  the 
clavicle.  The  tumour  was  covered  by  healthy,  non-adherent  skin. 
it  had  an  uneven  surface  and  was  remarkably  firm.  The  left  lobe 
was  soft  and  only  slightly  enlarged.  In  the  neighbourhood  of  the 
right  lobe  were  a  few  enlarged  glands:  The  larynx  was  somewhat 
pushed  over  to  the  left.     There  was  slight  paralysis  of  the  right 

*  Brit.  Med.  .Juurn..,  July  26,  1873,  p.  102. 

J  "Struma  Tuberculosa,"  Beitr.  :.  Id  in.  Clilr.,  Tiibingeu,  1893,  vol.  x.  p.  1. 


148  THE   THYROID    GLAND. 

recuri'ent  nerve,  but  the  voice  was  scarcely  at  all  affected.  \\  hen 
at  rest  there  was  no  stridor  or  dyspnoea,  but  these  symptoms  were 
present  on  exertion.  The  recent  rapid  and  painful  growth  together 
with  the  remarkable  firmness  and  irregularity  of  the  tumour  and 
the  enlargement  of  lymphatic  glands  led  to  the  suspicion  of 
malignancy.  Extirpation  of  the  right  lobe  of  the  tumour  was 
performed  without  any  difficulty  on  August  12,  1892,  and  the 
patient  made  a  rapid  recovery,  leaving  the  hospital  ten  days  after 
the  operation. 

"  The  half  of  the  thyroid  that  had  been  removed  was  of  firm  con- 
sistence and  somewhat  nodular  surface.  On  section  it  was  seen  to 
consist  chiefly  of  a  homogeneous,  grey,  firm  tissue  in  which  were 
embedded  a  number  of  isolated  masses.  These  masses  were  of  two 
kinds  :  numerous  small  circumscribed  nodules  up  to  the  size  of  a 
bean,  chiefly  near  the  periphery,  represented  I'emains  of  thyroid 
tissue,  partly  unaltered,  partly  having  undergone  colloid  degenera- 
tion, and  several  dry,  yellow  masses  of  the  size  of  walnuts,  which 
had  the  appearance  of  unsoftened,  cheesy  masses  like  those  observed 
in  the  so-called  granules  of  large-celled  tuberculous  lymphomata. 
At  the  lower  horn  of  the  lobe  was  a  collection  of  lymphatic  glands 
of  the  size  of  cherries,  loosely  united  by  connective  tissue." 

The  microscopical  examination  by  Dr.  Baumgarten  showed  tuber- 
culous tissue  with  the  usual  epithelioid  and  giant  cells. 

On  Nov.  2,  1892,  the  patient  returned  with  an  enlarged 
lymphatic  gland  in  the  neighbourhood  of  the  scar.  This  gland  was 
removed  and  showed  "typically  tuberculous '"  tissue.  No  tubercle 
bacilli  were  found  either  in  the  primary  growth  or  in  the  gland. 

Bruns  considers  the  case  to  be  "  undoubtedly  one  of  tubercle," 
and  Baumgarten  is  of  the  same  opinion. 

Syphilitic  Disease. — Syphilitic  disease  of  the  thyroid 
occurs  in  the  form  of  a  slig-ht  general  enlargement  in  the  earlv 
acute  stage  of  the  disease,  and  also  in  the  form  of  gummata  in 
the  tertiary  period. 

Engel  Reimers  *  considers  that  swelling  of  the  thyroid  gland 
occurs  in  nearly  half  the  cases  of  syphilis  in  their  early  stages. 
He  observed  it  eighty-six  times  among  one  hundred  and  fifty- 
two  women,  and  forty-four  times  among  ninety-eight  men  in 
the  early  stages  of  syphilis.  The  swelling  was  always  soft  and 
painless  and  caused  no  trouble. 

*  Jahrhuch  der  Jlamhurger  Staatshvanlienandalf,  vol.  iii.  p.  1894  (quoted  l)y 
Pur^t). 


TUBERCLE    AXD    SYPHILIS.  149 

In  this  country,  Mv.  C.  B.  I^ockwood  has  drawn  attention  * 
to  the  fact  that  slight,  and  generally  transient,  enlargement  of 
the  thyroid  gland  may  be  obscryed  in  the  acute  stage  of 
syphilis.  Haying  had  the  opportunity  of  seeing  Mr.  Lock^vood''s 
cases,  I  can  fully  corroborate  his  observation. 

The  enlargement  of  the  thyroid  in  this  early  stage  of  syphilis 
is  comparable  to  the  slight  enlargement  ^hich  is  met  with  in 
early  stages  of  measles  and  other  acute  specitic  diseases. 

^Ir.  Lockwood  obseryes  that  after  he  had  learnt  to  look  out 
for  this  thyroid  enlargement,  it  was  frequently  noticed  among 
his  yenereal  cases. 

Dr.  Moritz  Flirst  f  of  Hamburg  has  published  the  case  of  a 
child  born  with  a  goitre  of  considerable  size  which  he  con- 
siders to  haye  been  undoubtedly  caused  by  syphilis.  The  father 
had  suffered  from  this  disease,  and  the  mother  was  undergoing 
mercurial  treatment  during  her  pregnancy,  as  she  had  already 
given  birth  to  a  stillborn  syphilitic  child.  Each  lobe  of  the 
goitre  was  as  large  as  a  walnut.  The  swelling  almost  entirely 
disappeared  spontaneously  within  six  weeks  of  birth.  No  treat- 
ment was  adopted .  Dr.  Flirst  could  find  no  cause  for  the  goitre 
other  than  syphilis. 

Demme  ^  mentions  three  cases  seen  by  him  at  Berne  in  which 
children  with  congenital  syphilis  had  gummatous  nodules  in  the 
thyroid.  In  all  three  cases  the  liver  and  skin  also  presented 
signs  of  syphilis. 

The  only  museum  specimen  of  gumma  of  the  thvroid  gland 
with  which  I  am  acquainted,  is  in  the  Hoyal  College  of  Surgeons.  § 
It  is  thus  described  in  the  museum  catalogue  : 

Base  of  tongue,  laiynx  and  thyroid  gland,  sho-wing  gummatous 
infiltration  of  the  thyroid.  The  sterno-thyroid  muscle  is  matted  to 
the  left  lobe  of  the  thyroid,  which  on  section  has  a  white  fibrous 
appearance  towards  the  periphery,  while  the  centre  more  nearly 
resembles  normal  thyroid  tissue.  The  upper  end  of  the  trachea  is 
distinctly  stenosed,  and  it,  as  well  as  the  base  of  the  tongue,  shows 

*  St.  Bai-t.  Hosj).  BejUD-fs,  1895,  xxxi.  p.  232. 

t  "Ein  Fall  von  Struma  congenita  bei  elterliche  Syi^liiUs,"'  Berlin  lilin. 
Wochensc/u:,  1898,  xxxv.  p.  1016. 

j  In  Gerhardfs  Handhiich  der  Kinderliranlthelten,  liibingen,  1878,  vol.  iii. 
pt.  ii.  p.  413. 

§  Xo.  -IWoGr. 


150  THE   THYROID   GLAND. 

the  effect  of  past  ulceration.  Microscopic  sections  showed  a  fibroid 
tissue  richly  studded  with  nuclei.  From  a  woman  about  60  who 
■was  brought  into  the  hospital  dead.  There  were  gummata  in  the 
liver. 

Gummata  of  the  thyroid  have  also  been  described  by  Birch- 
Hirschfeld.* 

The  most  marked  example  of  gummatous  disease  of  the 
thvroid  that  has  come  under  mv  ow  n  notice  Avas  the  following : 

Mrs.  S ,  cef.  38^  was  admitted  into  St.  Bartholomew's  Hospital 

under  the  care  of  Mr.  Bruce  Clarke,  on  Dec.  28,  1896,  on  account 
of  dyspnoea  and  a  swelling  of  the  neck.  She  had  been  married 
thirteen  years,  but  had  never  been  pregnant.  For  the  last  four 
years  she  had  been  under  treatment  for  gummata  of  the  face  and 
arm.  About  six  weeks  before  admission  she  had  first  noticed  the 
swelling  in  the  neck.  There  was  no  historj^  of  any  pre-existing 
goitre.  Occupying  the  middle  line  of  the  neck  from  the  thyroid 
bone  to  the  sternum  Avas  a  prominent  hard  mass  moving  slightly 
with  the  larynx  on  deglutition.  The  skin  over  it  Avas  of  a  dull  red 
colour.  At  the  upper  part  was  a  deep,  circular  ulcer,  at  the  bottom 
of  which  was  a  hard,  yellowish  mass,  evidently  the  isthmus  of  the 
thyroid  gland.  There  was  no  obvious  enlargement  of  the  lateral 
lobes  of  the  gland.  On  the  fourth  day  after  admission  the  dyspnoea 
became  so  bad  that  laryngo-tracheotomy  had  to  be  performed  by 
the  house-surgeon,  Mr.  Pearson.  The  operation  Avas  difficult  owing 
to  the  thickness  of  the  tissue  that  had  to  be  divided  before  the 
cricoid  Avas  reached.  The  incision  Avas  made  through  a  thick  mass 
of  gummatous  thyroid,  most  of  Avhich  subsequently  sloughed  aAvay. 
The  patient  made  a  good  recovery  and  left  the  hospital  six  weeks 
after  admission.  The  wound  had  practically  healed,  but  there  was 
still  a  little  oedema  of  the  larynx  and  the  left  vocal  cord  did  not 
move  quite  freely.  It  seemed  probable  that  in  this  case  there  was 
some  necrosis  of  the  larynx  as  well  as  syphilitic  disease  of  the  thyroid 
gland. 

Mr.  Charters  Symonds  has  related  to  me  a  similar  case  of 
gummatous  disease  of  the  thyroid,  AA^hich  necessitated  trache- 
otomy. The  patient  Avas  a  man.  An  incision  Avas  made  right 
through  the  gummatous  disease  into  the  trachea.  The  patient 
recovered. 

*  "  Lehrbucli  d.  pathnlno'.  Aiuit."  4th  ed.,  181)4-.",  v...l.  W.  p.  472. 


TUBERCLE   AND    SYPHILIS.  151 

Dr.  Wermann  of  Dresden  has  published*  the  case  of  a  man, 
aged  24,  who  had  suffered  for  several  years  from  the  usual 
symptoms  of  syphilis.  He  had  undergone  prolonged  mercurial 
treatment  on  three  different  occasions,  and  was,  at  the  time  the 
goitre  developed,  undergoing  treatment  with  iodide  of  potassium 
on  account  of  a  gumma  of  the  soft  palate,  and  other  signs  of 
tertiary  syphilis. 

The  thyroid  swelling  was  general,  soft  and  painless.  It  gi'eAv 
rapidly  and  subsided  again  rapidly  under  mercurial  treatment. 
A  very  curious  point  about  this  goitre  is  that  it  developed 
Avhile  the  patient  was  taking  iodide  of  potassium,  a  remedy 
usually  so  effective  in  the  treatment  of  goitre. 

Fraenkel+  and  Kuttnerii:  have  also  written  upon  the  subject 
of  syphilis  of  the  thyroid. 

*  "'Uebei-  Luetische  Struma,"  Dr.  E.  "Wermann,  BerJ.ltllu.  Wofhemu-hr.,  1900, 
Xo.  6,  p.  122. 

f  "Ueber  Trachea  unci  Seliilddriisen  Sypliilis,"  i)?i/f«7/.  M<-(1.  Wurhe/ischr., 
1887,  p.  103.1. 

I  "Struma  Syphilitica,"  Beit/:  z.  Miu.  Chir.,  vol.  xxii.  part  2. 


CHAPTEK   X. 

CYSTIC    DISEASE. 

Frequency — Age — Modes  of  origin — Transition  oi:  adenoniata  into  eysts 
— Single  and  multiple  cysts — Hiemorrhagic  cysts — Structure  of  cyst 
wall — Of  contents — Vacuolation  of  colloid — Intra-cystic  growths — 
Malignant  nature  of — False  intra-cystic  growtlis. 

When  we  consider  the  vesicular  structure  of  the  normal  thyroid 
gland,  it  is  not  difficult  to  understand  how  readily  this  organ 
may  become  the  seat  of  cystic  disease.  By  cystic  disease  is 
meant  the  existence  of  one  or  more  cysts  considerably  larger 
than  the  normal  vesicles.* 

A  slight  degree  of  the  disease  is  extremely  common.  Out  of 
seventy-three  thyroid  glands  examined  consecutively  in  the 
post-mortem  room  of  St.  Bartholomew's  Hospital,  I  found  that 
no  less  than  twelve  contained  well  marked  cysts.  In  the 
majority  of  these,  however,  the  cysts  wei-e  small  and  few  in 
number,  and  could  not  have  been  detected  during  life;  in 
others,  however,  the  size  was  sufficient  to  cause  manifest  enlarge- 
ment of  the  gland. 

As  regards  the  age  at  which  cystic  disease  is  most  common, 
it  would  appear  that  middle-aged  and  elderly  people  are  more 
prone  to  the  affection  than  are  the  young.  Just  as  parenchy- 
matous disease  of  the  thyroid  is  the  most  common  form  of 
goitre  in  children  and  young  adults,  so  is  cystic  goitre  the  form 
which  is  most  often  met  with  in  people  of  more  advanced 
age. 

Mode  of  Origin. — Cysts  of  the  thyroid  may  originate  in 
any  of  the  following  ways  : 

1.  By  distension  of  one  or  more  of  the  natural  vesicles,  from 
accumulation  of  their  colloid  contents.     The  intervening  walls 

*   The  subiect  of  hydatid  cvsts  is  discussed  separate!)-  in  chapter  xi. 


CYSTIC   DISEASE. 


153 


of  contiguous  cysts  become  absorbed  and  small  cysts  thus  become 
fused  into  larger  ones. 


N 


4p 


Fig.  60. — From  a  girl  aged  10.    (St.  Bart.  Hosp.  Mns.  Xo.  231 4i.)  (Nat.  size.) 


Fig.  61. — From  a  •woman  aged  2.5.    (St.  Bart.  Hosp.  Mus.  Xo.  2314k.)   (Xat. 
size.) 
Figs.  GO,  61  and  62. — Three  specimens  illnstratiiig  the  gradual  Transforma- 
tion of  a  Solid  Thyroid  Adenoma  into  a  Cyst. 

If  a  thyroid  gland  which  is  undergoing  cystic  degeneration 
be  examined  with  the  microscope,  and  with  the  naked  eye,  it 
will  often  be  found  that  all  gradations  in  the  size  of  the  cysts 
may  be  seen. 


154 


THE   THYROID   GLAND. 


2.  Another  and  much  more  common  mode  in  which  large 
thyroid  cvsts  are  developed  is  from  adenomata  already  existing 
in  the  oland.  The  interior  of  the  softer  forms  of  adenoma 
frequently  breaks  down  and  liquefies  until,  eventually,  the 
capsule  of  the  adenoma  forms   the  wall  of  the  resulting  cyst. 


Figs.  60,  61  aud  62. — Three  specimeus  illustratini;-  the  gxadual  Transforma- 
tion of  a  Solid  Adenoma  into  a  Cyst.    Fig.  g2. — From  a  wumau 

ai;fil  41.     (St.  Bart.  Hosp.  Mus.  Xo.  2311n.)     (  x  f.) 

All  stages  between  the  completely  solid  adenoma   and  the  pure 
cyst  may  be  observed. 

Figs.  60  to  62  show  a  series  of  different  gradations  in  this 
process.  I  have  frequently  demonstrated  upon  the  inner  wall 
of  an  apparently  pure  cyst,  some  portion  of  adenomatous  tissue 
still  adhering  to  it,  and  thus  indicating  the  true  mode  of  origin 
of  the  cyst.  Indeed,  careful  examination  of  the  cyst  wall  with 
the  microscope  will  frequently  show  traces  of  thyroid  tissue   in 


CYSTIC  DISEASE. 


155 


Fig.  63.^A  sm-.ll  Tlm-oid  Cvi^t 
cut  tr^iusversely.  At  two  points 
ou  tlie  inner  surface  of  the 
cyst  w;ill  may  be  seen  traces 
of  tlie  oritiinal  solid  adenoma 
fi-om  which  the  cyst  was  de- 
veloped. From  a  middle-aged 
woman.     <X:it.  size.) 


the   inside  of   cvsts  which   at   first   sight   appeared    to    contain 

nothing  but  purely  fluid  contents. 
Fig.  63  is  taken  from  a  cyst,  which, 

at  first  sight,  appears  to  be  a  simple 

one.       Closer    examination,    however. 

reveals  traces  of  the  original  adenoma 

adhering    to    the  inner  surface  of  the 

cyst  wall. 

P"ig.  64,  from  a  specimen  in  St.  Bai'- 

tholomew's  Hospital   Museum,*  shows 

a  very  soft  adenoma  removed  bv  opera- 
tion.    Before,  and  at  the  time  of  the 

operation,  it  was  believed  to  be  a  pure 

cyst.     It    was    carefully    hardened  for 

some  days,  and  when  laid  open,  was  found  to  have  the  structure 

shown  in  the  figure. 
The  glandular  nature  of 
the  tumour  is  obvious. 

Probably  all, or  nearly 
all,  the  larger  cysts  met 
with  in  the  thyroid  gland 
originate  in  this  way 
fi'om  the  breaking  down 
of  a  pre-existing  ade- 
noma. Such  cysts  may 
attain  a  huge  size, 
measuring  several  inches 
in  diameter.  {See  Figs. 
65  and  67.) 

A  n  o  t  h  e  r  m  ode  in 
which  a  thyroid  cystmay 
originate  is  from  a 
haemorrhage  into  the 
organ. 

The  soft,  almost  fria- 
ble, nature  of  the  gland, 

especially    marked   when    parenchymatous   enlargement    exists, 

readily  permits  of  the  accumulation  of  blood  within   it.     This 

*    Xn.   231l)G. 


Fig.  64. — A  very  soft  Cystic  Adenoma.  The 
white  portions  show  e(>a<;nil:!ted  colloid  ui:iti'ii:il 
(St.  Bart.  Hosp.  Mns.  Xo.  2310G.)     iXat.  size.) 


156 


THE   THYROID   GLAND. 


blood  may  be  extra vasated  as  the  result,  either  of  slight  injury, 
or,  perhaps,  of  spontaneous  rupture  of  a  small  thyroid  vessel,  I 
do  not  consider  this,  however,  to  be  a  common  mode  of  origin. 


Fig.  65. — A  wuului.  a-ed  5u,  witli  a  l;irg-e  Cyst  '>i  the  l!iuhr  Lobe.  It 
had  been  growing'  slowly  for  more  than  twenty  years  and  caused  much 
discomfort  and  some  dy.spna?a.  It  was  easily  removed  by  resectioii- 
eniicleation.     (See  Appendix,  ('.ise  61.  p.  346.) 

Haemorrhage  into  an  adenomatous  tumour  is,  however,  very 
common. 

A  convenient  and  simple  classification  of  thyroid  cysts  is  into 
single  and  multiple. 

An  objection  to  this  classification  is  that  in  cases  of  single 
cyst,  there  exist  almost  alwavs  numerous  smaller  cysts  in  other 
parts  of  the  gland.     As  these  ho^vever  may  be  quite  small  and 


CYSTIC   DISEASE. 


157 


insignificant  in   comparison  with  the   larger  cyst,  the  practical 
value  of  the  classification  is  not  materially  affected. 

In  cases  of  multiple  cysts,  the  whole  gland  is  frequently  found 
to  be  converted  into  a  mass  of  cysts,  no  one  of  which  is  much 
laro-er  than  its  fellows. 


Fig.  66. — TIk-  precodiiii;.  iMif  week  alter  the  operation. 

Single  cysts  form  unilateral  tumour.s  ;*  multiple  cysts  generally 
produce  bilateral  enlargement  of  the  gland.  It  is  mainlv  on 
this  account  that  this  artificial  and  to  some  extent  incoiTect 
classification  is  worthy  of  adoption,  since  unilateral  and  bilateral 
tumours  frequently  present  much  difference  with  regard  to 
symptoms,  prognosis,  and  treatment. 

A  term  frequently  employed  is  that  of  Hcemorrhagic    cjj.st. 

*  Except  ■when  situated  exactly  in  tlie  middle  line,  which  is  not  common. 


158 


THE   THYROID    GLAND. 


This  may  be  of  the  nature  above  nieutioned,  but  is  much  more 
commonly  simply  an  ordinary  retention  or  adenomatous  cyst 
into  which  h;emorrhage  has  occurred. 

A  remarkable  peculiarity  of  thyroid  cysts  is  the  unusual  ten- 
dency to  intra-cystic  haemorrhage  which  they  possess. 

In  no  less  than  six  out  of  twelve  cases  mentioned  on  p,  152 


Fig.  67. — A  man,  aged  5U,  with  a  large  Siuglc  ThyroM  Cyst  siniiii;iiin' 
li-om  the  left  iipper  horn.  It  luul  been  gi'owiug-  slowly  lor  more  tliiiii 
thirtj'  years.  It  was  easily  and  successfully  removed  by  Dr.  Comte, 
and  found  to  contain  over  two  pounds  of  semi-solid,  partially  calcified, 
colloid  contents.  A  portion  of  the  c.yst  wall  and  its  contents  are  now 
in  the  Museum  of  St.  Bartholomew's  Hospital,  No.  2314f.  (Seen  at 
Geneva  in  1886.) 

distinct  intra-cystic  haemorrhage  had  occurred,  and  museum 
specimens  likewise  show  how  common  it  is  to  find  blood  in  the 
interior  of  a  thyroid  cyst.  In  no  other  class  of  cysts  is  found 
such  a  marked  tendency  to  haemorrhage.  If  a  thyroid  cyst  have 
been  tapped  and  clear  fluid  withdrawn,  a  second  tapping  is 
extremely  likely  to  evacuate,  not  a  clear  but  a  blood-stained 


CYSTIC    DISf^ASE.  159 

fluid ;    frequently    indeed    on    the    second    tapping     the    fluid 
consists  of  nearly  pure  blood. 

It  is  probable  that  the  explanation  of  this  tendency  to  blood 
extravasation  is  to  be  found  in  the  fact,  already  mentioned,  that 
many  thyroid  cysts  are  formed  from  pre-existing  adenomata. 
The  soft  and  vascular  thyroid  tissue  within  the  cyst  is  naturally 
very  apt  to  bleed. 

Occasionally  this  unfortunate  liability  to  haemorrhage  leads 
to  serious  or  even  fatal  results.  Professor  Kocher  relates  *  the 
case  of  a  lady  who  had  a  cyst  of  the  thyroid.  It  was  tapped  ; 
clear  fluid  being  withdrawn.  A  second  tapping  caused  the 
evacuation  of  pure  blood.  The  intra-cystic  haemorrhage  then 
caused  such  severe  dyspnoea  that  extirpation  of  the  cyst  had  to 
be  performed. 

Mr.  Butlin  has  kindly  communicated  to  me  a  case  in  which, 
many  years  ago,  a  thyroid  cyst  was  punctured  in  his  out-patient 
room  ;  such  severe  symptoms  were  caused  by  the  intra-cystic 
haemorrhage  which  ensued,  that  the  patient  subsequently  had 
to  be  admitted  to  the  hospital  as  an  in-patient,  and  the  haemor- 
rhage was  controlled  with  the  greatest  difficulty. 

In  the  College  of  Surgeons  Museum  is  a  preparation  f  of  a 
large  thyroid  cyst.  The  catalogue  states  that  the  cyst  was  full 
of  coagulated  blood,  and  looked  like  the  sac  of  an  aneurism. 
During  life  it  was  punctured  in  consequence  of  the  dyspnoea 
produced  by  its  pressure  upon  the  trachea.  A  considerable 
quantity  of  fluid  blood  flowed  from  the  wound,  and  the  bleeding- 
continued  until  the  patient  died. 

The  following  is  a  case  of  haemorrhagic  cyst  that  I  saw  in 
1885,  at  the  Kensington  Infirmary  with  Mr.  Potter  and  Dr. 
Reece.     (Fig.  33,  p.  47.) 

Mary  McD ,  a4.   60,  unmarried^   had  had  for  many  years  a 

swelling  in  the  situation  of  the  right  lobe  of  the  thyroid.  In  the 
last  two  months  it  had  become  much  lai'ger  and  more  prominent. 
In  the  above-mentioned  situation  was  an  irregular  rounded  swelling 
measuring  four  and  a  quarter  inches  transversely,  and  three  and 
three-quarters  vertically.  It  projected  considerably  and  over- 
lapped the  sternum  and  right  clavicle.  It  was  of  a  dusky  red 
coloui*,  tense  and  elastic,  but  with  softer  spots  here  and  there.     At 

*  Arehivf.  Mid.  C'/iir..  lSR;-5.  p.  308.  f  ^""o-  2905. 


IGO  THE   THYROID    GLAND. 

the  most  prominent  part  was  an  ulcer  with  a  slough  as  large  as  a 
sixpenny-piece.  Puncture  gave  exit  to  an  ounce  and  a  half  of 
grumous  fluid  containing  much  blood.  The  cyst  was  dissected  out 
by  Mr.  Potter  and  was  found  to  contain  a  lai'ge  amount  of  both 
fluid  and  clotted  blood.* 

The  patient  made  a  good  recovery. 

Haemorrhagic  cysts  of  other  parts  of  the  body  sometimes 
afford  a  presumption  of  malignancy,  but  this  is  by  no  means 
the  case  with  those  of  the  thyroid.  Malignant  cysts  of  this 
organ  like  those  of  other  parts,  may,  of  course,  be  accompanied 
by  intra-cystic  haemorrhage.  But  it  is  important  to  bear  in 
mind  that  the  finding  of  blood  in  the  interior  of  a  thyroid  cyst 
ought  not  in  itself  to  be  taken  as  pointing  towards  the  existence 
of  malignant  disease. 

On  the  other  hand  malignant  disease  of  the  thyroid  may 
produce  cysts  containing  clear  fluid.  Two  examples  of  this 
have  come  under  my  own  notice. 

The  situation  in  which  cysts  are  most  often  found  is  the 
lower  part  of  one  or  other  lateral  lobe,  but  the  only  apparent 
reason  for  their  more  frequent  occurrence  in  this  part  is  that 
the  main  bulk  of  the  organ  is  situated  here.  The  isthmus  and 
the  comparatively  slender  upward  prolongation  of  the  lateral 
lobes  form  but  a  small  part  of  the  whole  organ,  t 

The  structui'e  of  thyroid  cysts  may  conveniently  be  considered 
under  two  heads : 

(a)  Structure  of  the  cyst-wall. 

(b)  Structure  of  its  contents. 

(a)  Cyst-wall. — In  small  recently  formed  cysts,  the  wall  has 
the  same  structure  as  that  of  the  normal  vesicle ;  it  consists  of 
an  exceedingly  thin  and  delicate  layer  of  connective-tissue  lined 
by  a  single  layer  of  epithelial  cells. 

In  larger  cysts  it  is  more  fibrous  and  tough,  being  composed 
mainly  of  dense  layers  of  fibrous  tissue  closely  packed  together. 

Sometimes  when  the  cvst  is  large  the  wall  may  measure 
several  lines  in  thickness.     In  these  cases  there  may  often  be 

*  This  specimen  is  now  in  the  Museum  of  tlie  Koyal  College  of  Surgeons. 
No.  290oA. 

j  For  specimens  of  cyst  in  upper  part  of  lateral  lohe.  see  St.  George's  Hosp. 
Mus.  No.  20A  :  in  isthmus.  St.  Mary's  Hosp.  Mus.  1031.  ,'<rp  nl.w  Figs.  41 
and  67. 


CYSTIC   DISEASE.  l6l 

found  in  it  spicules  or  hard  flat  plates  of  calcareous  matter.  In 
cystic  o;oitres  of  long  standing,"  the  whole  wall  may  be  one  large 
calcareous  plate. 

According  to  Dr.  Paul  Koch  *  the  calcareous  plates  consist  of 
a  mixture  of  carbonate  and  phosphate  of  lime. 

Many  hospital  museums  contain  specimens  of  calcified  thyroid 
cysts.  Some  of  these  haye  been  macerated  and  dried  ;  others  are 
wet  preparations. •*■ 

The  inner  surface  of  the  cyst-wall  yaries  considerably.  In 
small  cysts  it  is  generally  of  a  yellow  or  brow-nish  colour.  In 
larger  ones  with  thick  fibrous  walls  it  is  white,  smooth  and 
glistening,  if  the  fluid  contents  have  been  clear.  If  the  latter 
have  been  thick,  discoloured  and  opaque  then  the  cyst- wall  may 
be  rough  or  be  lined  with  layers  of  fibrin,  or  colloid  material ; 
or  with  pus,  if  suppuration  have  occuiTed. 

(b)  Contents  of  the  Cyst. — The  simplest  cysts  contain  the 
ordinary  yellowish,  slightly  viscid,  colloid  mateiial  secreted  bv 
the  lining  membrane.  When  the  cyst  is  large,  however,  the 
contents  become  more  or  less  altered. 

The  fluid  may  be  clear  and  watery.  In  the  case  of  a  man 
aged  47,  with  a  single  cyst  as  large  as  a  small  orange,  I  find  in 
my  notes  that  the  fluid  was  thin,  of  a  light  straw  colour,  slightly 
alkaline.  On  standing,  a  small  coagulum  separated  out ;  the 
remaining  fluid,  on  boiling,  yielded  a  precipitate  of  albumen 
(two-thirds).  It  also  contained  a  moderate  amount  of  chlorides 
and  some  cholesterin.  This  may  be  taken  as  a  fair  example  of 
the  clear  fluid  contained  in  a  very  common  class  of  cyst. 

The  fluid  may,  and  very  commonly  does,  contain  blood  which 
may  vary  in  amount  from  a  mere  trace  to  a  quantity  which 
forms  a  very  large  proportion  of  the  total  fluid.  The  colour 
may  therefore  be  almost  any  shade  of  red  or  brown. 

Frequently  the  colloid  contents  are  much  more  viscid.  They 
may  then  present  the  appearance  of  a  stiff"  jelly. 

Further  changes  may  have  occurred  and  the  jelly-like  material 
have  become  more  or  less  solidified  and  dried  up. 

*  "  Cas  interessant  de  goitre  kj'stique  presente  -k  la  Soc.  des  sciences  med. 
de  Luxemboiu-g,"  A)in.  des  mal.  de  Voreille  ef  du  larynx,  Pai-is,  1881,  vii.  86-90. 

t  See  Univ.  Coll.  Mus.  1361  ;  St.  Bart.  Hosp.  Mus.  2316  and  2317 ;  Guy's 
Hosp.  Mus.  122  and  123  ;  King's  Coll.  Mus.  280  ;  also  an  unnumbered  specimen 
in  the  Geneva  Path.  Mus. 


162  THE   THYROID   GLAND. 

Frequently  points  of  calcification  may  be  seen,  or  these  may 
have  developed  into  large,  calcareous  masses.  A  cyst  removed 
by  M.  Comte  of  Geneva,  which  I  had  an  opportunity  of 
examining  (.see  Fig.  67),  contained  more  than  two  pounds  of 
half  dried  partially  calcified  colloid  material  of  this  nature.  A 
small  portion  of  this  tumour  is  now  in  the  museum  of  St.  Bar- 
tholomew's Hospital.* 

Sometimes  the  calcification  is  so  extensive  that  the  whole 
tumour  is  converted  into  a  dense  calcareous  mass.f 


Fig.  68. — Parein'hymatoiis  Goitre  fi-om  a  girl  aged  17.  Several  distcuded 
vesicles  are  seen  with  colloid  that  lias  imdergoue  the  chauges  described 
on  p.  163.     (X   9u  diam.) 

It  is  by  no  means  uncommon  to  find  crystals  of  cholesterin 
among  the  contents  of  an  old  thyroid  cyst.  [J: 

Occasionally  the  solid  contents  of  a  thyroid  cyst  may  be  found 
in  the  form  of  loose  masses  in  the  interior  of  the  cyst.  In  the 
museum  of  pathology  at  Geneva  is  a  very  remarkable  specimen 
of  a  large   cyst   which   contained   many  hundreds  of  rounded, 

*  No.  2314F. 

t  An  excellent  example  of  tliis  condition  is  to  be  seen  in  the  Pathological 
Museum  at  Pragtie. 

J  For  examples  of  this  condition  see  seven  of  the  cases  reported  by  Keser  in 
his  monograph,  ■'  L"  enucleation  on  extirpation  intra-glandulaire  du  goitre  paren- 
chymateux."  Paris.  1887. 


CYSTIC   DISEASE. 


163 


crenate  loose  bodies  of  about  the  size  and  shape  of  blackberries. 
Two  of  these  bodies  together  with  a  small  portion  of  the  cyst- 
wall  may  be  seen  in  the  Museum  of  the  Royal  College  of 
Surgeons.* 

Microscopical  examination  of  the  colloid  material  found  in 
the  smaller  thyroid  cysts  will  generally  show  a  number  of  little 


Fig.  69. — Srction  of  a  Parenchymatous  Goitre  with  Commencing' 
Cystic  Degeneration.  Somu  of  tire  cysts  are  coalescing  and 
thus  produce  a  false  impression  of  cysts  with  intra-cystic  growths. 
From  a  girl  aged  17.     (St.  B:irt.  Hosp.  Mtis.  Xo.  2312a.)     (Keduced  §.i 

round  cavities,  some  at  the  edge  and  some  in  the  middle  of  the 
mass. 

These  vacuoles,  which  are  shown  in  the  centre  of  Fig.  68,  are 
probably'  due  merely  to  post-mortem  changes  in  the  colloid  and 
have  no  pathological  signification. 


*  No.  290oB.     See  also  a  figure  in  my  paper  ou  the 
the  Trans.  Path.  Soc,  1890,  vol.  xl.  p.'264. 


Patholoo'v  of  Goitre  "  in 


164  THE   THYROID   GLAND. 

Intra-eystic  growths. — Occasionally  papillomatous  growths 
spring  from  the  wall  of  a  thyroid  cyst  and  project  into  its 
cavity.  A  beautiful  specimen  *  of  a  cyst  of  this  nature  was 
exhibited  by  Mr.  Bilton  Pollard,  at  a  meeting  of  the  Patho- 
logical Society  in  1885.  These  papuliferous  cysts  are  distinctly 
rare.  They  must  be  carefully  distinguished  from  the  common 
cysts  in  which  adenomatous  tissue  is  found,  which  is  merely  the 
remains  of  a  pre-existing  adenoma. 

True  papuliferous  cysts  of  the  thyroid  are  analogous  to  the 
corresponding  tumours  of  the  ovary  and  breast,  and  like  them 
have  a  low  degree  of  malignancy.  They  tend  to  recur  after 
removal,  and  to  become  eventually  distinctly  carcinomatous  in 
structure.  They  will  be  described  more  fully  in  the  chapter  on 
malignant  disease.  A  false  appearance  of  intracystic  growth  is 
often  produced  by  the  remains  of  septa,  which  existed  between 
small  cysts.  When  these  cysts  coalesce  to  form  larger  cysts, 
the  septa  together  with  adherent  masses  of  thyroid  tissue  pro- 
duce a  condition  which  at  first  sight  closely  resembles  that  of  a 
cyst  with  true  intracystic  growths. 

This  appearance  is  well  shown  in  the  upper  part  of  the 
specimen  depicted  in  Fig.  69. 

Remains  of  adenomatous  tissue  within  a  cyst  may  also  present 
a  superficial  resemblance  to  true  intracystic  growths. 

*  For  a  drawing  of  this  specimen  see  Path.  Sue.  Trans..  1886,  xxxvii.  511. 


CHAPTER   XL 

HYDATIDS. 

Rarity  of — Museum  specimen — Age — Sex — Absorption  of  gland  by 
pressure  —  Sj'mptoms  —  Suppuration  —  Diagnosis  —  Urticaria — Rupture 
into  trachea — Treatment — Table  of  cases. 

The  only  parasite  of  importance  that  is  known  to  occur  in  the 
thyroid  gland  is  the  echinococcus  (hydatid).  Even  this  is  not 
very  often  seen  in  this  situation. 

Most  of  our  knowledge  of  hydatids  of  the  thyroid  has  been 
obtained  from  the  writings  of  Gurlt,  Dardel,  and  Henle,  who 
have  collected  and  described  all  the  cases  known  to  them, 
seventeen  in  all.*  To  these  I  have  been  able  to  add  five  others, 
one  of  them  hitherto  unpublished.  {See  tal)le  of  cases  at  the 
end  of  this  chapter,  pp.  172-175.) 

These  bring  the  total  number  of  recorded  cases  up  to  twenty- 
two.  Short  notes  of  all  of  them  are  given  in  the  table  at  the 
end  of  the  chapter. 

The  only  museum  specimen  of  a  hydatid  of  the  thyroid  with 
which  I  am  acquainted  is  in  Guy's  Hospital  Museum. f 

It  is  thus  described  in  the  museum  catalogue  : 

*  Besides  these,  there  are  a  good  many  cases  of  hj'datid  close  to.  but  not 
actually  in  the  thyi'oid  gland  itself  ;  among  these  are  Dixon's  well-known  case 
{Med.  Ghir.  Trans,  vol.  xxxiv.  p.  31.5),  J.  L.  Reverdin's  {Journal  de  la  Suisse 
Romande,  1885,  p.  421),  and  those  of  Cloquet,  Langenbeck,  Laennec,  Bock,  and 
Duquet.  Other  cases  again  have  been  described  as  hydatids  of  the  thj'roid  in 
which  the  evidence  of  the  hydatid  nature  of  the  disease  was  too  slender  to 
warrant  me  in  including  them  in  my  table.  The  inclusion  of  Bock's  case  in  the 
lists  of  vmdoubted  hydatids  of  the  thjToid  given  by  Gm-lt  and  Henle  is  CAddently 
due  to  a  misciuotation  from  the  original  paper  {Lehrh.  der  Path.  Anat.  u 
Blagmstik,  3rd  ed.  vol.  i.  p.  554).  Some  of  the  above  may  have  been  cases 
of  hydatid  of  the  thjToid,  but  have  not  been  included  in  my  table  owing  to 
want  of  evidence. 

t  No.  124. 


166"  THE   THYROID   GLAND. 

"  Tlie  remains  of  a  hydatid  cyst  removed  from  the  thyroid  gland. 
Histologically  the  wall  of  the  cyst  is  composed  of  characteristic 
laminated  membrane. 

•■Emma  W.  at  15  was  admitted  under  Mr.  Cock  for  a  swelling 
of  the  neck  of  seven  years  duration.  It  was  thought  to  be  a  broncho- 
cele.  The  swelling  was  twice  incised  and  pus  evacuated  ;  subse- 
quently the  cyst  was  removed,  and  the  patient  made  a  good 
recovery.  See  Surgical  Reports  1855,  case  274;  and  Tra?hs.  Path. 
Soc.  18.qO,  p.  270." 

The  .specimen  shows  pieces  of  characteristic  hydatid  membrane 
without  any  thyroid  tissue. 

Hydatids  occui-  with  about  ecjual  frequency  in  the  two  sexes 
(9  male,  11  female  cases). 

They  have  been  seen  at  all  ages  from  14  (cases  5  and  9) 
to  60  (case  6),  but  much  more  often  below  the  age  of  40  than 
above  it.  Of  21  cases  in  which  the  age  is  known,  in  5  only 
were  the  patients  above  the  age  of  40. 

The  hydatid  in  most  cases  presents  itself  in  the  form  of  a 
single  cyst,  but  occasionally  two  or  more  have  been  found  in 
the  gland  (case  6).  As  in  other  parts  of  the  body,  the  hydatid 
may  be  present  with  or  without  daughter  cvsts.  Sometimes  it 
has  been  found  in  a  calcified  condition  (case  6). 

In  some  of  the  cases  in  which  post-mortem  examinations  were 
made,  hydatids  in  other  organs  were  found,  e.g.^  in  the  liver 
(case  5),  liver  and  uterus  (case  8),  kidneys  (case  6). 

In  some  cases  the  hydatid  has  been  found  in  a  thyroid  which 
Avas  already  the  seat  of  ordinary  goitre,  but  in  the  majority 
of  the  cases  there  seem  to  have  been  no  history  of  pre-existing 
goitre. 

The  hydatid,  as  it  grows,  tends  to  cause  pressure  absorption 
of  the  lobe  of  the  gland  in  which  it  lies,  just  as  an  ordinary  cyst 
or  adenoma  would.  In  some  cases  the  glandular  tissue  around 
the  hydatid  has  thus  been  converted  into  a  mere  capsule  of  fibrous 
tissue  containing  the  flattened  remains  of  thyroid  vesicles. 
Henle  remarks  that  this  absorption  of  the  gland  on  one  side 
may  lead  to  a  certain  amount  of  compensatory  hypertrophy  of 
the  opposite  lobe,  as  in  case  17. 

Symptoms  and  Diagnosis. — The  usual  history  of  a  hydatid 
cyst  of  the  thyroid  is  that  of  a  slowly  increasing  painless  tumour 


HYDATIDS.  167 

which  has  existed  for  months  or  years  ;  in  one  case  (case  6)  it 
had  existed  for  not  less  than  forty-one  years.  Like  other  cysts 
of  the  thyroid  no  symptoms  are  produced  until  the  tumour  has 
become  sufficiently  large  to  press  upon  surrounding  organs. 
Then  pressure  svmptoms  occur  which  are  precisely  similar  to 
those  produced  bv  ordinary  unilateral  goitre.  In  nearly  all  the 
recorded  cases  it  is  stated  that  more  or  less  dyspnoea  was  present 
sooner  or  later.  In  case  1,  sudden  death  was  produced  by 
the  rupture  of  the  cvst  into  the  trachea.  In  case  5,  death 
appears  to  have  resulted  from  direct  pressure  upon  the  trachea. 
In  several  other  cases  the  amount  of  dyspnoea  was  considerable. 
Dysphagia  and  dvsphonia  are  not  usually  prominent  symptoms. 

The  tumour  when  small  is  usually  globular  or  oval,  hut  when 
large  and  projecting  from  the  surface  of  the  gland,  it  may  be 
very  irregular  in  shape.  In  these  cases  fluctuation  is  easily 
obtained. 

A  hydatid  thrill  does  not  appear  to  have  been  noticed  in  any 
case. 

A  tendency  to  spontaneous  suppuration  is  wortn  noticing, 
owing  to  the  danger  of  suppuration  in  this  region.  In  at  least 
five  of  the  recorded  cases  (cases  3,  11,  17,  21,  and  22)  spon- 
taneous suppuration  occurred  ;  in  others  it  occurred  only  after 
tapping. 

The  diagnosis  of  a  hydatid  cvst  of  the  thyroid  gland  is  very 
difficult.  Indeed  it  would  appear  that  a  positive  diagnosis  has 
not  hitherto  been  made  in  a  single  instance  without  a  pre- 
liminary puncture,  and  only  a  few  times  even  after  puncture 
(cases  10, 19,  20,  of  Galozzi,  Lannelongue,  and  Karpetchenco). 

The  Avithdrawal  bv  puncture  from  a  thyroid  cyst  of  a  clear 
limpid  colourless  fluid  should  raise  a  suspicion  of  the  hydatid 
nature  of  the  cyst.  If  chemical  examination  show  this  fluid  to 
contain  little  or  no  albumen,  but  abundant  chlorides,  or  if  the 
microscope  show  booklets  or  bits  of  membrane,  then  the  diagnosis 
is  confirmed. 

In  most  cases  the  diao-nosis  has  not  been  made  until  charac- 
teristic  echinoccoci  or  pieces  of  hydatid  membrane  have  been 
evacuated  by  incision. 

The  rapid  and  irregular  enlargement  of  a  tumour  that  has 
long  been  quiescent  is  not  verv  uncommon  with  a  hydatid  of  the 


168  thp:  thyroid  gland. 

thyroid,  and  niav  lead  to  a  suspicion  of  malignancy.*  The 
youthful  age  of  the  patient  will,  however,  usually  point  in  the 
opposite  direction.  The  diagnosis  between  a  suppurating 
hydatid  cyst  and  suppuration  of  a  simple  thyroid  cyst  must 
be  well-nigh  impossible. 

The  presence  of  a  hydatid  cyst  in  the  liver  or  elsewhere  in 
the  body  might  throw  some  lii^ht  on  the  diagnosis  of  the 
thyroid  swelling,  but  does  notactuallv  seem  to  have  done  so  in 
any  of  the  hitherto  recorded  cases. 

The  presence  of  urticaria  may  be  of  the  greatest  help  in  the 
diagnosis.  It  was  partly  from  the  existence  of  this  symptom 
that  Lannelongue  (case  19),  according  to  \  itrac,  arrived  at  a 
correct  diagnosis.  This  case  is  so  interesting  and  instructive 
that  it  seems  worth  while  to  grive  it  at  some  length. 

Hydatid  of  the  t/u/roid ;  urticaria;  alternating  disappearaiice  and 
re-appearance  of  the  tumour  and  of  the  urticaria.  Puncture  and 
injection.      Cure. 

Jean  H ,  cet.   3i,   a   teacher,  was   admitted   on   Januaiy  31, 

1896,  into  the  hospital  of  Saint- Andre  at  Bordeaux  under  the  care 
of  M.  Lannelongue. 

About  the  middle  of  1892,  the  patient,  when  buttoning  his 
shirt,  noticed  in  the  left  antero-lat.tral  region  of  the  neck,  a  little 
above  the  sternum,  a  tumour  as  large  as  an  egg.  It  was  a  little 
fixed  at  its  deeper  part  but  was  movable  under  the  skin.  For 
four  or  five  months  the  tumour  grew  slowly  until  it  had  attained 
the  dimensions  of  a  man's  fist.  It  then  began  to  cause  him  some 
local  discomfort  and  soon  afterwards  he  noticed  an  itching  of 
various  parts  of  the  body  which  led  him  to  scratch  himself.  Some 
trouble  in  breathing  and  swallowing  had  lasted  about  a  fortnight 
when  suddenly,  in  the  space  of  a  minute  or  two,  all  the  local 
symptoms  disappeared,  and  at  the  same  time  the  tumour  vanished 
so  completely  that  nothing  but  a  very  slight  amount  of  local 
swelling  was  left.  Ihe  itching  however  became  more  intense. 
The  tumour  was  absent  for  three  months  ;  then  during  the  next 
four  months  it  gradually  returned  to  its  original  size.  The 
slight  dyspnoea  and  dysphagia  also  gradually  returned  but  the 
itching  troubled  him  much  less.  The  intensity  of  this  sympton 
was  always  in  inverse  proportion  to  the  size  of  the  cyst.  The 
patient  had  abundant  opportunities  of  observing  this  point,  for  up 

*  See  Eeverdin"s  case  of  hydatid  cyst  of  the  thyroid  region,  quoted  above. 


HYDATIDS.  169 

to  September  1894,  the  tumour  had  thus  disappeared  and  re- 
appeared no  less  than  three  times.  The  patient  now  consulted 
a  doctor,  who  with  a  Pravaz  syringe  drew  off  some  absolutely  limpid 
fluid.  The  small  quantity  withdrawn  did  not  appreciably  diminisli 
the  size  of  the  swelling.  Xevertheless  half  an  hour  later,  no  trace 
whatever  of  the  tumour  could  be  detected.  A  violent  attack  of 
urticaria  followed  and  for  seven  months  there  was  no  sign  of  the 
tumour.  But  in  May  1895;,  it  began  to  appear  again  and  grew 
until  in  August  it  was  again  as  large  as  a  fist.  In  December  it  was 
not  larger  than  an  egg,  but  then  it  again  began  to  grow,  and  he 
came  into  the  hospital. 

On  admission  the  tumour  was  again  as  large  as  a  fist  and  the 
patient  was  anxious  for  treatment,  especially  as,  besides  the 
dyspnoea  and  dysphagia,  there  was  now  some  alteration  in  his 
voice. 

The  patient  was  in  other  respects  healthy.  At  the  root  and  left 
side  of  the  neck  was  an  irregular  swelling.  The  thyroid  cartilage 
was  displaced  1^  centimetres  (f  in.)  to  the  right  of  the  middle  line. 
The  tumour  was  crossed  obliquely  by  the  sterno-mastoid  which  thus 
gave  it  a  bilobed  appearance.  It  extended  vertically  from  the 
sternum  to  the  upper  border  of  the  thyroid  cartilage,  laterallv  from 
the  middle  of  the  left  supra-clavicular  fossa  to  the  inner  border  of 
the  right  sterno-mastoid.  It  was  movable  laterallv  with  the  trachea 
but  not  vertically  unless  the  patient  swallowed.  But  when  the 
trachea  was  raised  in  the  performance  of  this  act,  the  tumour  was 
tilted  from  above  downwards.      There  was  no  pain  or  tenderness. 

The  liver  was  slightly  enlarged  but  there  was  no  evidence  of  anv 
definite  tumour  in  it. 

The  diagnosis  of  a  fluid  tumour  of  the  thyroid  admitted  of 
no  doubt.  The  characters  of  the  liquid  previously  withdrawn,  but 
esjiecially  the  phenomena  of  disappearance  and  re-appearance  of 
the  tumour  and  the  urticaria,  were  the  signs  which  enabled 
M.  Lannelongue  to  make  the  diagnosis  of  hydatid  cyst.  The 
diagnosis  was  confirmed  a  few  days  later  by  puncture  and  the  with- 
drawal of  800  grammes  (10  ozs.)  of  a  liquid  as  clear  as  water, 
containing  S  grammes  of  chlorides,  no  mucin  and  very  little 
albumen  ;  neither  heat  nor  acetic  acid  gave  any  precipitate.  There 
were  no  booklets.  After  the  evacuation  of  the  cyst,  no  tumour 
could  be  felt  ;  the  walls  of  the  cyst  were  evidently  very  thin.  Ic 
was  washed  out  several  times  with  sublimate  lotion  1  in  1000.  For 
two  or  three  days  there  was  slight  pain,  and  a  little  albumen 
appeared  in  the  urine.      The  urticaria  did  not  re-ajjj^ear. 

The  patient  was  seen  again  two  months  and  six  monihs   later. 


170  THE   THYROID    GLAND. 

Tlie  neck  appeared  absolutely  normal.     The  patient  was  considered 
to  be  absolutely  cured. 

Treatment. — The  treatment  of  a  hydatid  cyst  must  depend  to 
a  certain  extent  upon  the  nature  of  the  hydatid.  If  it  be  an 
acephalocyst,  as  in  Lannelongue's  case  just  mentioned,  a  simple 
tapping  and  injection  with  corrosive  sublimate  solution  may 
suffice  to  affect  a  cure. 

In  most  cases,  however,  the  presence  of  daughter  cysts  will 
necessitate  some  larger  operation.  The  choice  of  operation  will 
then  lie  between  incision  of  the  cyst  with  suture  of  its  walls  to 
the  skin,  and  complete  removal  by  enucleation.  Extirpation  of 
the  whole  thyroid  lobe  is  seldom  desirable. 

If  the  tumour  is  small  and  not  inflamed,  the  best  method  of 
treating  it  is  by  enucleation,  just  as  would  be  done  in  the  case 
of  an  ordinary  thyroid  cyst.  In  fact,  owing  to  the  difficulty  of 
diagnosis,  it  is  probable  that  the  operation  would  be  undertaken 
on  the  supposition  that  the  tumour  was  a  simple  cyst.  In 
M.  Peyrofs  case  (case  12)  this  was  the  diagnosis.  Enucleation 
was  easily  performed,  and  was  followed  by  primary  union. 

In  most  of  the  cases,  however,  in  Avhich  enucleation  has  been 
attempted,  the  operation  has  been  attended  with  considerable 
difficulty,  owing  to  the  firm  connections  existing  between  the 
cvst  and  surrounding  parts. 

In  Chavier's  case  (case  18)  the  attempt  to  enucleate  had  to  be 
abandoned  on  account  of  haemorrhage,  and  the  cut  edges  of  the 
cvst  were  sewn  to  the  cut  edges  of  the  skin. 

In  V.  Bergmann's  case  (case  15)  the  enucleation  was  so  difficult 
that  it  was  not  considered  advisable  to  complete  it,  so  a  part  of 
the  cyst  wall  was  left  behind ;  the  wound  was  packed  for  two 
days,  and  then  a  secondary  suture  was  performed.  The  patient 
was  cured  in  nine  days. 

In  Zoege-ManteuffePs  case  also  (case  16),  the  inner  part  of 
the  cyst  wall  that  was  adherent  to  the  trachea  had  to  be  left 
behind. 

In  Mikulicz's  case  (case  17),  the  attempted  enucleation  was 
replaced  by  an  atypical  extirpation ;  a  similar  operation  was 
performed  by  Stanley  Boyd  (case  22).  In  both  of  these  cases, 
the    contents  of  the   cyst    were  purulent.     The  inflammation, 


HYDATIDS.  171 

doubtless,  added  considerably  to  the  difficulty  of  the  opera- 
tion. 

In  cases,  therefore,  in  which  the  cyst  is  large,  or  in  which 
there  is  or  has  been  much  inflammation,  it  seems  best  not  to 
make  any  attempt  to  remove  the  whole  cyst,  but  to  content 
oneself  either  with  incising  the  cyst  wall,  scraping  out  its 
contents  and  sewing  the  edges  to  those  of  the  skin,  or  with 
excising  the  anterior  portion  of  the  cyst  wall. 

It  should  be  remembered  that  the  cyst  wall  consists  of  two 
layers  ;  the  inner  layer  (endocyst)  can .  generally  be  removed 
without  any  difficulty.  It  is  the  outer  layer  only  (ectocyst)  that 
is  difficult  to  remove.  A  portion  of  this  at  least  must  usually 
be  left  behind  owine*  to  the  adhesions  and  to  the  danger  of 
wounding  surrounding  important  structures,  such  as  the  recur- 
rent laryngeal  nerve  or  the  oesophagus.     (See  case  22.) 


172 


THE   THYROID   GLAND. 


O 
ai 
>^ 

X 

E-i 

O 

w 

Q 

< 

G 
>^ 

O 
w 

G 

G 
Pi 
O 

Cj 

O 


o 

•2  ^i;  O 

r-  •  ^ 

.•  -H  OC  '^  ^'' 

•>  l-S  CO 

30 
l4 

,  "Cases  an 
il  Remarks 
,"  etc.,  2nd 
orwich,  17( 

£■ 

» 

■=   C   >-.'?^ 

T     '^  '•'^ 

"      -  *    A* 

^■^  .   . 

S 

5  "-f  .J  ._• 

^^1 

~  "^ '"' 

~t^ 

~"  'X  J 

^-- 

1     a:    ;; 

bo 

a: 

a: 

4S 

S     K   HJ 

■^ 

i 

_CD  ^ 

3.S   C 

^ 

y. 

O  -w    S    C-C 

o  >?-r 

r. 

O  '^  '-^     ~ 

^     ...    r^. 

^^  |.|  .= 

^ 

r; 

•oof 

a: 

'-" 

^  S  .S  '"• 

ocS'J-tiS'^..,"",.^- 

"  f  1  "  "B-'  "  ^  "5  ^  53  2P 
IT  f^  "^  qT  :;  LT  2  -i:  )=^  a;  S 

?-f  X    ^     O 


—      IJ      3      ;_    .-.      ^        -      -      J 


-e  o      cs  2  t^ 


o  ^ . 


■  'ipS---i  s's  a?' 


P  '-fi  g  o  ~  p 


S-="   F^cf-S 

.2  s  j:  <i^  -t2 

'^  a;  .::^  r^  id 
if-  rS  _  ^  o 
5j         C   rt   3 


ai    n   ,-    -.    — 

o  ^  s  a  ;= 


2.  p  2  j2  >: 


O    5  Vj    i:^ 


...  o£i  ^    p  -tJ 

.  2  II  .|  ^ 
.t'  E  3  S  -^ 


2   ai 


Q  2 


3  f= 
^•2 


a  2^^ 

3  ^  ■■*::; 


2'   ^ 

5=    C    ^ 

.„ 

a 

CD 

'rt.S    ■ 

p 

> 

9  E 

0 

1 

3 
% 

■0 
> 
? 

cS   cT 

3j  g 

r^ 

i  c  ^ 

^ 

bCcS 

.  'f-- 

•^  .1; 

>.•'-  i 

a 

S 

8 
d 

■X       w 

ti  s 

>."S  s 

s 

>~.  '^ 

r- 

0 
be 

s  =^  ^ 
=  ?^  -^ 

-ji 

0 

ID 

aj 

t3 

.   0 
9  % 

a 
0 

"a; 

-^  '? 

^"^  • '  .t: 

be 

3 

3 

GC 

CC 

^    CD 

o.S 

111 
:e  bxj  ■^- 

TJl 

0 

CO 

■3  0 

o.s 

cc 

in 

Q 

(M 

•~a 

-* 

0 

.0 

03 

-3 

a 

0 

(D 

-H 

CO 

a 

m 

(U 
fe 

g 

1; 

S 

HYDATIDS.  173 


£  -  y- 


sq; 


^  >  o  1 

Y. 

-ti  .^    ^    ^. 

- 

c^    -*-*'""'    r^ 

c^ 

^  >.-2^ 

. 

s 

S"^  -5  oj^ 


b  5 


c5  -2      S  -/:  ^  '-^  ^  ^  -"  5"^ 


:i  -1 1  ?  §-|  1^- 1         ^  ~  1 1  J  |--  -^  I  ^  I  ^  I  I'f  ' 


gcp-^    =    -3    = 


;=  2  :"•" 


174 


THE   THYROID   GLAND. 


OO 

, 

1. 

•^ 

• '  fCi 

**r 

^  1— < 

« 

X 

o 

g    P. 

o 

'x 

^  — 

CC 

^  o 

_5 

d 

5  i^ 

X 

'^ 

_ 

■>  ^  IN 

U 
2 

^2 

j^ 

1^; 

i'« 

X 

X 

c^ 

~    C^ 

H 
g 

h 
S 

If 

C     r 
c3  S 

6 

X 

3D 

bt  5^ 

"  Si 
1 

an 

CC 

> 

c 

33 15  & 

Is 

OJ 

■ij 

S 

•=  -^^  c  0  c  , 

—     /-    c3  •--  ,    C 

e: 

=* 

S 

^  ^-  0  -§  t  ^ 

-r. 

< 

53  o 

It 

5  § 

2 

"t:    :-    —    15    ^    X 

It? 'II 

S  c  "rt  -^  J  ^s 

be 

K 

r-  "^ 

"Pa 

S 

33 

.—    2    w    --  ' 

5 

^~^  ^ 

-,  :3 

-^  r^    ;>   o;   oj   C3 

U( 

5  ■> 

1"? 

f  .-g  ■=  ^  1  s 

X 

J 

"o 

^ 

H 

0'  ^  'c  °S  rt 

•r. 

-g 

■x 

^ 

X 

15 

>■ 

^ 

"-^ 

■^ 

r; 

cc 

,—1 

^_^ 

-- 

0 

J 

— - 

Z.   ?^ 

t-H 

P 

■" 

^ 

.~ 

""■  a 

— 

o 

6 

s 

IS 

:£ 

i 

X 

5  5 
11 

= 

1 

s  1  S 

it""  "S 

ct 

o 

.§ 

X 

■■■  i  >~.:^  bt 
.-"s  =  "  ^  2 

1  ."l 

s 

r. 

i 

i 

o  S 

X 

-^^ 

s 

J  > 

1 

"C 

•— 

= 

§  E.  =  .|  i  -^ 

PS 

o 

'  -f. 

'"3 

o 

OJ 

■-5  o 

5 

"33 

1 

;2 

"5 

■^ 

^ 

IE  £  'ti  -^  ol  ii 

s 

HH 

^ 

^ 

^ 

;^  Sh 

33 

"i3 

^ 

t£ 

^iili 

ac 

"3  o 

/2 

cT 

bti 

b(j 

rS 

be 
if. 

Tc 

'ii 

be  a, 

X 

1 

i. 

■y-  S  s  c  S 

O 

C    1 

p 

aj 

bL 
J/. 

;2 

•J. 

:'; 

x" 

5  = 

_ 

D 
t*^ 

'x 

¥■ 

^.s'^  ^  i  _ 

+3  ^ 

1 

3 

53 

O 

jiT 

if. 

Tc 

-  ? 

X* 

X    % 

X 

Tt 

i 

S 

"x 

. — '     15  ti.^    —  •" 

O 

2  ^ 

1 

5 

*x 

X 

15 

>  .» 

£ 

i  1 

^ 

ei 

ij 

i. 

■35 

X 

g    2     0    =     i^ 

■s. 

■^"i. 

X 

p. 

s 

= 

5 

?^  i" 

X    <D 

O 

X 

5 

r  -5  "ti  "S   bt 

^ 

o   — 

"S 

>i 

s 

— 

S 

— 

>>  ;^. 

'^"q-. 

s 

:^ 

," 

^"-  "be  -    r*^ 

•Z^  o 

^ 

■^ 

-^ 

C 

.^ 

a_ 

3 

CC    rH 

1-H      O 

-f^ 

^ 

-"   ^'r^   S    " 

X 

"" 

- 

E 

^ 

M 

=^ 

v:  " 

5^ 

1^ 

X 

— 

IN 

iS 

f— 1 

^ 

r— 

,^ 

-5 

CC 

15 

"E 

X  <! 

j; 

■^ 

j5 

■^ 

X 

'Z- 

g 

I 

^ 

05 

d 

V. 

-f 

■n 

to 

t~ 

K 

'^ 

'"' 

'^ 

'"' 

^ 

^    ^ 


HYDATIDS.  175 


7Z     ^ 

C  -  ^5  i  ^  N  -r  •?.  -■ 

>  ~    i 


i;  ^1  ^  ~ 


31   :r 


=  -_  ?      >-.-e  >-.  •-  i 


CHAPTER   XII. 

EXOPHTHALMIC  GOITRE  AND  ITS  TREATMENT. 
(GRAVES'S  DISEASE  ;  BASEDOW'S  DISEASE.) 

Age — Sex — Pathology — Morbid  anatomy — Characteristic  appearance  on 
section — Microscopical  appearance — Absence  of  accumulated  colloid — 
Secondary  changes — Exophthalmos — Cause  of — Enlargement  of  thymus 
- —  .Symptoms  and  Diagnosis  —  "  Formes  fiuistes  "  —  Treatment  : 
Medical.  Surgical — Operations  upon  the  thp-oid — Extirpation — Results 
— ExotliATopexy — Operation  upon  vessels — Operation  upon  sjTnpathetic 
— Section  —  Resection — Unilateral  —  Bilateral — Results — Mortality — 
Prognosis  without  operation — Conclusions. 

A  DETAILED  description  of  the  remarkable  disease  known  as 
exophthalmic  goitre  would  be  out  of  place  in  a  book  which  deals 
mainly  with  the  surgical  aspect  of  diseases  of  the  thyroid  gland. 
A  short  description  only  will  be  given  here. 

The  disease  is  found  to  occur  in  both  sexes,  but  is  far  more 
common  in  women  than  in  men. 

During  the  fifteen  years  1884  to  1898,  there  were  in  the 
medical  wards  of  St.  Bartholomew's  Hospital  ninetv-six  admis- 
sions for  exophthalmic  goitre.  Of  these  eightv-eight  were 
female  \\liile  only  eight  were  male  cases. 

True  exophthalmic  goitre  is  almost,  if  not  cjuite,  unknown 
before  the  period  of  pubertv  and  rarely  begins  after  middle  age. 
It  is  confined  almost  exclusively  to  the  period  of  sexual  activitv 
and  is  especially  common  in  the  earlier  part  of  that  period. 

Of  the  above-mentioned  ninety-six  cases,  twelve  were,  on 
admission,  between  the  ages  of  fifteen  and  twenty,  forty-five  were 
between  twenty  and  thirty,  twenty-six  between  thirty  and  forty, 
while  only  thirteen  were  over  forty. 

Exophthalmic  goitre  does  not  occur  as  an  endemic  disease, 
and  is  not  especially  common  in  districts  where  ordinary  goitre 
is  endemic.     Amons;  a  thousand  cases  of  goitre  seen  by  Dr. 


EXOPHTHALMIC    GOITRE. 


177 


Savage  in  a  goitrous  district  in  the  north  of  England,  there  was 
not  a  single  case  of  Graves's  disease.  Dr.  Montoya  v  Florez, 
Professor  of  Clinical  Surgery  at  Medellin,  Columbia,  tells  me 
that  although  endemic  goitre  is  extremelv  common  in  that 
country,  he  has  never  seen  there  a  case  of  exophthalmic  goitre. 
My  own  inquiries  in  many  goitrous  districts  both  in  England 


Fig.  70. — A  tjiiieal  case  of  Exophthalmic  Goitre  ( Graves's  Disease) 
in  a  yoiiug-  nomau.  (Seen  in  a  meditMl  ^^aril  at  St.  Bartholomew's 
Hospital.) 


and  abroad  point  in  the  same  direction,  and  tend  to  show  that 
exophthalmic  goitre  is  rare  in  places  where  ordinary  goitre  is 
common,  and  certainly  is  often  found  to  exist  in  places  where 
ordinary  goitre  is  unknown. 

Dr.  Maude,  on  the  other  hand,  whose  writings  on  exophthalmic 
goitre  are  so  well  known,  appears  to  think  that  there  is  some 
connection  between  the  distribution  of  the  two  diseases. 


178  THE    THYROID   GLAND. 

Pathology. — It  must  be  confessed  that  the  pathology  of  the 
disease  is  still  obscure.  The  numerous  theories  that  have  been 
brought  forward  may  be  divided  into  three  main  classes,  in 
which  the  cause  of  the  malady  is  attributed  to  disease  respect- 
ively of  the  central  nervous  system,  the  cervical  sympathetic, 
and  the  thyroid  gland. 

For  a  full  discussion  of  the  various  theories  reference 
must  be  made  to  works  on  medicine.  With  regard  to  the  first 
two  it  is  sufficient  to  say  that  they  are  unsupported  by  reliable 
post-mortem  evidence.  Slight  changes  in  the  brain  and  the 
sympathetic  nerve  have  from  time  to  time  been  described.  In 
the  great  majority  of  cases,  however,  in  which  post-mortem 
examinations  have  been  made,  no  definite  lesion  has  been  dis- 
covered in  either  of  these  structures.  Neither  an  irritative  nor 
a  paralytic  lesion  of  the  sympathetic  will  account  for  the 
symptoms  of  the  disease.  These  symptoms,  moreover,  are  not 
those  which  we  know  to  be  the  result  of  gross  lesions  of  the 
sympathetic.  The  idea  that  the  enlargement  of  the  gland  is 
due  to  vascular  dilatation  seems  to  lie  at  the  root  of  the 
sympathetic  theory. 

This  idea  has  arisen,  I  am  afraid,  mainly  from  clinical  examina- 
tion of  the  gland  ;  the  actual  investigations  of  morbid  anatomy 
do  not  support  it. 

Recent  researches,  especially  those  of  Mobius,  Greenfield  and 
Murray  point  strongly,  in  my  opinion,  to  the  view  that  the 
primary  source  of  the  disease  lies  in  the  thyroid  gland,  in  which 
alone  definite  and  remarkable  lesions  are  always  found.  The 
complex  group  of  symptoms  which  characterise  the  disease  are 
probably  caused  by  an  alteration  of  the  internal  secretion  of 
this  o-land.*  The  secretion  appears  to  be  altered  in  quantity 
and  probably  in  quality  also.  This  altered  secretion,  when 
circulating  in  the  body,  probably  acts  directly  or  indirectly,  like 
many  other  poisons,  upon  the  heart,  upon  the  nervous  system, 
and  upon  the  nutrition  of  many  tissues  in  the  body. 

*  How  far  this  thjToid  disease  is  dependent  upon  some  unlcnown  disease  of 
the  higher  centres  of  the  hrain  is  an  interesting  question  which  need  not  be 
discussed  here.  There  is  at  least  some  evidence  to  show  that  violent  emotions 
such  as  fright  may  be  the  immediate  cause  of  the  disease.  (See  an  excellent 
paper  by  Dr.  Raymond  Cra\\'furd.  "  Graves's  Disease  :  an  emotional  disorder," 
Kinrfs  Coll.  HoajK  Eejn^.,  vol.  iii.  1897.) 


EXOPHTHALMIC   GOITRE. 


179 


Morbid  Anatomy. — A  museum  specimen  of  a  typical  exoph- 
thalmic o-oitre  is  usually  easily  distino-uished  from  the  other 
forms  of  goitre.  Like  the  purely  parenchymatous  goitre,  all 
parts  of  the  gland  are  equally  enlarged.  The  enlargement  is 
rarely  excessiye  ;  each 
lateral  lobe  seldom 
exceeds  in  dimensions 
those  of  a  goose''s  egg, 
and  is  often  much 
smaller.  The  surface 
is  smoother  than  that 
of  a  parenchymatous 
croitre.  It  is  the  cut 
surface  of  the  gland, 
howeyer,  that  presents 
the  most  characteristic 
appearances.  This 
shows  a  remarkably 
homogeneous,  solid 
structure,  yery  unlike 
the  yesicular  appear- 
ance of  a  parenchy- 
matous goitre.  Little 
or  no  colloid  is  yisible. 
The  blood -yessels  are 
usually  smaller  and  less 
numerous  than  in  a 
parenchymatous  goitre 
of  the  corresponding 
size.  This  point  is,  I 
think,  important,  since 
it  is  often  stated  by 
those  who  appear  not 
to  haye  inyestigated 
the  matter  for  themseiyes  that  there  is  "  great  dilatation  of  the 
yessels.""* 

Microscopical    examination    of    the    thyroid    shows    marked 

■'  I  quote  liere  the  words  of  a  well-knowu  medical  authority  who  -nTOte  them 
in  1897. 


Pic.  71. Sketch  of  Tliyi-oid  Gland   and  ueighboxu-ing- 

parts,  fi-om  an  unmarried -svoman  aged  19,  tlie  suljject 
of  ExopMhalmic  Goitre.  The  enlargement 
of  tlie  tli3-mus  (the  lower  part  of  which  has, however, 
been  cut  off)  is  characteristic.  (St.  Bart.  Hosp.  Mus. 
Xo.  2314T.>     (Keduced  J.) 


180 


THE    THYROID    GLAND. 


differences  between  the  exophthalmic  and  the  common  paren- 
chymatous goitre.  Instead  of  the  vesicles  distended  Avith  colloid 
secretion  and  lined  with  a  single  layer  of  cubical  epithelium, 
which  are  seen  in  the  ])arenchymatous  goitre,  we  find  in  the 
exophthalmic  variety  a  wholly  different  appearand'.  The  colloid 
is  much  reduced  in  quantity,  and  indeed  is  frequently  almost 
entirclv  absent.     The  vesicles  are  not  distended  and  are  not  at 

all  well  marked.  The 
epithelial  lining  has 
undergone  a  marked  pro- 
liferation so  that  the  place 
of  the  vesicle  is  frequently 
taken  by  an  irregular  mass 
of  round  cells  with  per- 
haps a  trace  of  colloid. 
There  is  also  a  tendency 
for  the  epithelium  to 
become  columnar.  The 
whole  gland  appears  to  be 
in  a  state  of  considerable 
physiological  activity, 
but  the  secretion,  instead 
of  beino-  accumulated  in 
the  vesicles,  is  not  to  be 
seen,  having  apparently  passed  into  the  lymphatics  as  soon  as 
secreted.  An  extreme  case  presents  considerable  superficial 
resemblance  to  a  round-celled  sarcoma. 

The  accompanying  micro-photographs  (Figs.  73  and  74) 
illustrate  the  appearance  of  parenchymatous  and  exophthalmic 
goitre  respectively. 

The  appearances  above  mentioned  are  those  which  are  found 
in  all  severe  cases,  that  is  in  all  cases  in  which  the  disease  itself 
has  been  the  immediate  cause  of  death.  They  are  practically 
identical  in  all  museum  and  post-mortem  room  specimens  that 
I  have  had  the  opportunity  of  examining.  There  is  no  museum 
specimen  with  which  I  am  acquainted  which  shows  the  "great 
dilatation  of  vessels'"  to  which  allusion  has  been  made.* 

*  Excellent  specimens  of  exophthalmic  goitre  may  be  seen  in  the  following 
museums  :  Roy.  Coll.   Surg.   2891a  ;  Guy's  Hosp.   99,  100,  and  101  ;  St.   Bart. 


Fig.  72. — The  prccediug,  seen  from  Ijehiiid.  A 
.suction  ol  tlie  left  lobe  has  beeu  iii:ide,  showiug- 
the  homogeneous,  solid  stritctiu-e  of  the  giand. 
(St.  Bart.  Hosp.  Miis.  Xo.  2314T.)     (Keduced  i.) 


EXOPHTHALMIC    GOITRE. 


181 


If  the  examination  be  made  of  an  exophthalmic  goitre  from  a 
case  in  which  death  has  occurred  not  wholly  from  the  disease  itself. 


'j.'ar^y^^iitij'  ^^'cj'c**. 


"o  ^  =  I  £  .5 

eS   -  •-  :t  ;z  - 

^  ;  I  I  .ii  : 

I— I  "r    "  ~         3 

ft  ii  -S  &  =   ^ 

§  i  ~  1 1  = 


-     —     5^    -^ 


?;>:^'' 

--'pr  "■'* 

c     _     > 


_:£  3 

y 

£ 

—     o    '^    ^ 

■^ 

Ip  1 

> 

s 

5 

_ 

C    O    ii  ~ 

— 

•- 

I  s  i 


^£  ft  =  i-    =  ■?   = 
3  o  g   p  ^  >  ^ 


^  :§  ^  i  I  c  i 

^1  "^  ^*  ^  Ei  ci;  § 

'-  "  ^  2  ,2    ^  .2 

:  g  .  X  M  'S 


a  £ 


Ho^p.  23US.  T.  and  r  :  Chai-.  Cross  Hosp.  879a  ;  St.  Marr  s  Hosp.  102.5  ;.  Univ. 
Coll.  Hosp.  li58D:  St.  Thomas-s  Hosp.  li65A.  Some^vhat  less  tj-pical  ai'e 
Gurs  Hosp.  102  and  Westm.  Hosp.  609. 

*  Case  of  A.  H.,  at.  15,  described  in  £rit.  Med.  Journ.  July  20,  1891. 

t  Unpublislied. 


182  THE   THYROID   GLAND. 

the  appearances  presented  are  similar  but  not  so  ]>ronounced. 
A  good  deal  of  colloid  may  be  seen  and  many  vesicles  may 
still  be  easily  recognisable.  Opportunities  for  examining  such 
specimens  are  occasionally  afforded  at  the  present  time  bv  opera- 
tions for  the  removal  of  the  goitre. 

Cysts  and  adenomata  are  rarelv  met  with  in  the  goitre  of 
Graves's  disease,  and  this  is  probably  one  reason  why  this  form 
of  goitre  seldom  attains  a  very  large  size. 

A  thyroid  gland  containing  a  pre-existing  cyst  or  adenoma 
may,  hoAvever,  subsequently  develop  the  characters  of  Graves's 
disease,  and  it  is  probably  such  cases  that  have  led  occasionally 
to  the  description  of  unilateral  exophthalmic  goitre.  True  and 
uncomplicated  exophthalmic  goitre,  being  a  disease  of  the  whole 
organ,  is  never  unilateral. 

An  exophthalmic  goitre  of  long  standing  may  develoj) 
secondary  changes,  such  as  fibi'osis,  similar  to  those  of  paren- 
chymatous goitre.     Examples  of  this,  however,  are  rare. 

The  exophthalmos  is,  I  believe,  due  entirely  to  a  local  deposit 
of  fat  behind  the  eyeball.  No  reliable  post-mortem  evidence  of 
its  being  due  to  any  other  cause  has  ever  been  brought  forward. 
The  absurd  theory  that  it  is  due  to  vascular  dilatation  of 
the  orbital  vessels  scarcely  merits  discussion.  The  vessels  that 
supply  the  post  ocular  tissues  (branches  of  the  ophthalmic 
artery)  supply  also  the  conjunctiva  and  eyelids,  both  of  which 
are  easily  examined  by  simple  inspection.  They  do  not  show 
any  increased  vascularity  in  Graves's  disease.  On  the  other 
hand,  increased  orbital  vascularity  is  a  condition  with  which  we 
are  all  familiar.  It  is  often  seen  in  cases  of  inflammation  of  the 
orbit  and  of  tumour  or  thrombosis  at  the  back  of  the  orbit. 
In  these  cases,  the  proptosis  which  is  often  present,  is  accom- 
panied by  suffusion  of  the  conjunctiva,  and  often  by  swelling  of 
the  eyelids.  This  condition  of  affairs  differs  widely  from  that  of 
Graves's  disease,  in  which  the  visible  parts  of  the  orbit  are  not 
only  not  more  vascular,  but  often  positively  paler  or  less  vascular 
than  in  health.  Why  there  should  be,  in  this  di-^ease,  an 
increase  of  orbital  fat,  is  a  question  that  cannot  at  present  be 
answered.  But  we  do  know,  at  any  rate,  that  there  is  in 
Graves's  disease  a  tendency  to  local  deposition  of  fat  in  other 
parts  of  the  body,  such  as  the  face  and  anterior  abdominal  wall. 


EXOPHTHALMIC    GOITRE.  183 

It  is  not  unreasonable  to  assume  that  the  same  cause  that  leads 
to  local  deposil  ion  of  fat  in  these  regions  may  also  cause  it& 
deposition  in  the  orbits. 

The  theory  that  the  exophthahnos  is  due  to  spasm  of  muscle 
is  wholly  insufficient  to  account  for  the  amount  of  exophthalmos 
that  is  generally  present  in  an  ordinary  case  of  Grayes's 
disease. 

A  yery  common,  if  not  constant,  accompaniment  of  the 
disease,  is  a  great  enlargement  of  the  thymus  gland,  ^yhich 
forms  a  thick  solid  mass,  sometimes  weighing  several  ounces. 
This  enlargement  may  be  detected,  during  life,  by  careful  per- 
cussion oyer  the  upper  part  of  the  sternum.  The  pathological 
significance  of  this  undue  persistence  and  enlargement  of  the 
thymus  is  unknown.* 

Symptoms  and  Diagnosis. — The  three  cardinal  symptoms  of 
Grayes's  disease  are  : 

(1)  Prominence  of  the  eyeballs  (exophthalmos). 

(2)  Rapidity  of  the  heart  (tachycardia)  with  palpitation. 

(3)  Enlargement  of  the  thyroid  gland  (goitre). 

In  most  cases,  howeyer,  some  or  all  of  the  following  symptoms 
are  also  present. 

(4)  Neryous  symptoms,  especially  tremulousness  and  excit- 
ability ;  often  the  patient  shows  a  marked  change  of  habits  and 
tastes,  and  a  condition  resembling  acute  mania  is  by  no  means 
unknown. 

(5)  Diarrhoea. 

(6)  Glycosui'ia. 

(7)  Pigmentation  of  the  skin,  usually  of  a  patchy  nature. 

(8)  Local  accumulation  of  subcutaneous  fat,  especially  on  the 
anterior  abdominal  wall, 

(9)  Sweating,  and  consequent  lessened  electrical  resistance  of 
the  skin. 

(10)  Breathlessness. 

(11)  Slight  eleyation  of  temperature. 

The  clinical  picture  presented  by  a  patient  in  the  advanced 
stages  of  the  disease  is  usually  quite  characteristic,  and  there  is 

*  Good  specimeus  of  thi^^  enlargement  of  the  tliATQUS  may  be  .^een  in  the 
following  museums  :  St.  Mary's  Hosp.  1025  ;  Univ.  Coll.  Hosp.  13.58D  ;  St. 
Thos.  Hosp.  1-KJ5A  :  St.  Bart.  Hosp.  2314T  and  2314r. 


184  THE   THYROID    GLAND. 

i]o  dirticulty  in  the  diagnosis.  {Sec  Fig.  70.)  In  some  cases, 
however,  one  or  more  of  the  three  cardinal  symptoms  is  absent, 
and  then  there  may  be  much  difficulty  in  the  diagnosis. 

The  enlargement  of  the  thyroid  may  be  so  slight  as  scarcely 
to  attract  attention.  Even  when  it  is  well  marked  there  are  no 
meann  bij  ic/iieh  ice  can  dlst'ing'ui.sk  it  ic'itli  eerta'intij  from  the 
simple  parenchymatous  enlargement.  The  gland  usually 
presents  a  somewhat  smoother  and  more  rounded  surface,  and, 
occasionally,  a  feeling  of  firmness,  of  plumpness  and  solidity  has 
seemed  to  me  to  afJbrd  help  in  the  diagnosis.  Pulsation  in  the 
gland,  and  the  presence  of  a  bruit  are  not  in  themselves  charac- 
teristic, since  they  are  often  found  in  parenchymatous  goitres. 
A  thrill  is  often  felt.  It  is  important  to  bear  in  mind  that  the 
increased  pulsation  of  the  thyroid  vessels  is  not  greater  than 
that  of  the  other  vessels  in  the  body. 

The  exophthalmos  is  almost  invariably  bilateral  and  sym- 
metrical. Cases  of  unilateral  exophthalmos  due  to  Graves's 
disease  are,  however,  said  to  occur ;  but  such  cases  have  never 
come  under  my  notice. 

Exophthalmos  is  by  far  the  most  characteristic  symptom  of 
the  disease,  although  its  presence  is  not  absolutely  essential  for 
the  diagnosis.  When  exophthalmos  is  absent  the  diagnosis  is 
much  more  difficult.  Ordinary  parenchymatous  goitre  is  fre- 
quently accompanied  by  cardio-vascular  symptoms.  Persistent 
frequency  of  pulse  with  goitre  is  sufficient  to  raise  a  strong 
suspicion  of  Graves"'s  disease,  and  a  careful  examination  should, 
in  such  cases,  be  made  to  see  whether  any  of  the  other  symptoms 
exist. 

It  is  in  the  early  stages  of  the  disease  that  the  diagnosis  is 
most  important,  especially  from  the  surgical  point  of  view.  I 
have  several  times  seen,  and  successfully  operated  upon,  patients 
with  goitre  and  rapidity  of  pulse,  who  had  been  considered, 
erroneously,  to  be  suffering  from  Graves's  disease.  Probably, 
many  of  the  reported  cases  of  cure  after  operations  for  atypical 
Graves's  disease  (the  ^o-CQS\&d^formeHf rusted  of  the  French)  have 
not  Jbeen  cases  of  Graves's  disease  at  all.  This  may  account 
for  the  cures.  On  the  other-  hand,  it  is  important  that  the 
surgeon  should  not  overlook  the  existence  of  this  disease  in 
its  early  stage.     By  doing  so,  he  may  make  the  serious  mistake 


EXOPHTHALMIC   GOITRE.  185 

of  undertaking  to  treat,  by  surgical  means,  a  goitre  which 
probably  ought  not  to  be  interfered  with. 

In  the  absence  of  exophthalmos,  the  persistently  rapid  pulse, 
the  clammy,  tremulous  hand,  and  the  fidgety,  nervous  manner  of 
the  patient  afford,  according  to  mv  own  experience,  the  best 
means  of  diagnosis. 

Dyspnoea  is  of  course  a  common  .symptom  in  both  parenchy- 
matous and  exophthalmic  goitre.  In  the  former  disease, 
however,  the  dyspnoea  is  alwavs  produced  by  direct  pressure  on 
the  trachea,  and  is  accompanied  by  stridor.  In  the  latter,  the 
dyspnoea  appears  to  be  due  to  cardio-vascular  changes.  An 
exophthalmic  goitre  only  rarely  produces  an  appreciable  degree 
of  pressure  upon  the  trachea,  and  is  consequently  not  usually 
accompanied  by  stridor. 

There  are,  however,  rare  cases  in  which  an  exophthalmic 
goitre  does  cause  serious  pressure  upon  the  trachea  and  it  may 
even  become  necessary  to  perform  tracheotomy  for  the  relief  of 
the  dyspnoea. 

At  the  meeting  of  the  Pathological  Society  of  London,  held 
on  INIarch  3,  1891,  Mr.  W.  G.  Spencer  showed  a  specimen  of 
exophthalmic  goitre  which  had  caused  death  by  suffocation. 
The  patient  was  a  girl,  aged  20,  who  had  suffered  for  at  least  a 
year  from  the  ordinary  symptoms  of  exophthalmic  goitre, 
namely,  prominence  of  the  eyeballs,  rapidity  of  pulse,  and 
thyroid  swelling.  Dyspnoea  became  so  severe  that  tracheotomy 
had  to  be  performed;  this  was  attended  with  much  difficulty; 
the  trachea  was  opened  above  the  isthmus,  and  an  elastic  tube 
four  inches  long  had  to  be  passed  down  the  trachea  beyond  the 
obstructed  portion  before  relief  was  afforded.  In  a  few  hours 
the  dyspnoea  returned,  the  patient  was  unable  to  expectorate 
through  the  tube,  and  death  occurred,  apparently  by  suffocation 
from  the  accumulation  of  mucus  in  the  trachea  and  bronchi. 

The  goitre,  which  is  at  present  in  the  Westminster  Hospital 
Museum,*  was  a  large  bilateral  one,  tolerably  homogeneous  in 
structure,  but  differing  from  most  exophthalmic  goitres  in  con- 
taining much  fibrous  tissue  and  numerous  small  cysts.  None  of 
these,  however,  are  larger  than  small  peas.  The  trachea  was 
greatly  flattened  from  side  to  side  down  to  within  an  inch  of 

*  No.  (309. 


186  THE   THYROID   GLAND. 

the  bifurcation.  The  presence  of  cysts  and  of  much  fibrous 
tissue,  and  a  history  of  the  goitre  having  been  present  for  very 
manv  years  ("  all  her  life,"  it  was  alleged),  show  that  this  case 
was  not  entirely  typical.  It  is  quite  possible  that  this  was 
really  a  case  of  ordinary  parenchymatous  goitre  to  which 
Graves's  disease  had  recently  been  added. 

In  the  Lancet  of  February  7,  1891,  Dr.  Hugh  Montgomerie 
reported  "  a  case  of  exophthalmic  goitre,  ending  fatally  from 
sudden  pressure  on  the  trachea,"  in  a  woman  of  thirty-five.  In 
this  case  also  the  goitre  was  unusually  large,  and  the  symptoms 
do  not  seem  to  have  been  very  characteristic  of  Graves's  disease. 
A  low  tracheotomy  was  performed,  but  without  success.  A 
post-mortem  examination  revealed  extreme  tracheal  stenosis  ; 
the  goitre  was  not  a  symmetrical  enlargement  of  the  thyroid, 
showing  that  the  case  was  not  one  of  pure  exophthalmic  goitre. 

Treatment.  Medical. — Numerous  drugs  have  been  recom- 
mended for  the  treatment  of  this  most  troublesome  malady,  but 
none  of  them  can  be  considered  to  be  thoroughly  satisfactory. 
Most  of  them  do  not  do  more  than  alleviate  symptoms, 
especially  the  palpitation. 

Something  can  be  done  by  such  hygienic  measures  as  rest  and 
change  of  surroundings.  Removal  to  a  higher  altitude  often 
causes  considerable  relief. 

Digitalis  is  often  given  to  quiet  the  circulation  and  diminish 
palpitation.  Belladonna  appears  to  be  useful  sometimes  ;  it 
may  have  some  effect  in  diminishing  the  thyroid  secretion. 

Thyroid  extract  has  also  been  given,  but  it  seems  clear  that 
it  not  only  does  no  good,  but  is  positively  harmful.  This  is  only 
what  might  be  expected  if  the  disease  is  due  to  over-activity  of 
the  gland. 

Thymus  feeding  has  also  been  tried,  but  with  doubtful  benefit; 
the  undoubted  connection  between  enlargement  of  the  thymus 
and  Graves's  disease  is,  however,  worth  remembering  in  con- 
nection with  this  method  of  treatment.  Ord  and  Hector 
Mackenzie,  having  made  an  extensive  trial  of  thymus  gland 
preparations  in  twenty  cases,  came  to  the  conclusion  that  "  no 
appreciable  effect  followed  their  administration.* 

Iodine  and  its  preparations,  so  potent  in  the  treatment  of 
*  Clifford  Allbutt's  "  System  of  Medicine;'  1897,  vol.  iv.,  p.  507. 


EXOPHTHALMIC   GOITRE.  187 

parenchymatous  goitre,  are  not  only  useless  in  Graves's  disease, 
but  usually  aggravate  the  symptoms.  Mobius  speaks  highly  of 
the  value  of  bromine  preparations.*  Iron  is  sometimes  beneficial, 
and  seems  to  be  indicated  in  cases  in  which  there  is  marked 
anaemia. 

The  application  of  cold  to  the  neck  by  means  of  Leiter  s 
tubes  appears  to  relieve  the  patient's  distress  in  many  cases,  but 
does  not  exert  anv  curative*  effect  upon  the  disease. 

Treatment  by  electricity,  both  galvanic  and  faradic,  has  been 
strongly  recommended,  but  does  not  seem  to  be  of  any  more  use 
than  other  remedies.  A  strong  current  may  have  some  bene- 
ficial influence  upon  the  patient's  mental  condition. 

The  medical  treatment  of  a  case  of  exophthalmic  goitre  does 
not,  however,  come  within  the  province  of  a  surgeon,  who  is 
content  to  hand  the  case  over  to  a  physician.  For  further 
details  of  the  medical  treatment,  about  which  volumes  have 
been  written,  a  Avork  on  medicine  must  be  consulted. 

Surgical. — Although,  in  my  opinion,  the  treatment  of  exoph- 
thalmic goitre  belongs  essentially  to  the  physician  and  not  to 
the  surgeon,  it  is  right  that  some  account  should  here  be  given 
of  the  various  forms  of  surgical  treatment  that  have  been  from 
time  to  time  adopted  by  surgeons.  Especially  in  the  last  few 
years  has  surgical  treatment  been  recommended  and  practised 
by  some  surgeons.  The  different  forms  of  operative  treatment 
that  have  been  employed  for  exophthalmic  goitre  may  be  divided 
into  the  following  groups : 

1.  Operations  upon  the  thyroid  gland  itself. 

2.  Operations  upon  the  thyroid  vessels. 

3.  Operations  upon  the  cervical  sympathetic  nerve. 

4.  Operations  upon  distant  parts  of  the  body. 

1.  Operations  upon  the  Thyroid  Gland. — Most  of  the  oper- 
ations that  have  been  practised  for  parenchymatous  goitre  have 
also  been  employed  for  exophthalmic  goitre.  Those,  such  as 
injection  with  iodine,  which  act  by  causing  inflammation  and 
obliteration  of  the  vesicles,  are  not  suitable,  for  the  simple 
reason  that  in  this  disease  we  are  not  dealing  with  distended 
vesicles  at  all,  but  with  a  condition  of  epithelial  proliferation. 
The  absence  of  colloid  in  an  exophthalmic  goitre  renders 
*  Arcli.f.  Esychiat.,  Berlin,  1898-9,  xxxi.,  p.  923. 


188  THE   THYROID    GLAND. 

division  of  the  isthmus  also  a  futile  operation  ;  the  shrinking 
of  a  parenchymatous  goitre  after  division  of  the  isthmus  is 
due,  as  is  shown  elsewhere,  to  the  draining  away  of  the  con- 
tents of  the  vesicles.  In  an  exophthalmic  goitre  there  is  no 
accumulated  colloid  that  can  be  drained  awav. 

P'or  a  similar  reason  intraglandular  enucleation,  so  excellent 
for  the  treatment  of  manv  simple  goitres,  is  not  applicable  here, 
because  there  are  here  no  encapsuled  tumours,  and  it  is  upon 
these  alone  that  enucleation  can  be  performed.  In  those  atypical 
cases  in  which  Graves's  disease  has  been  superadded  to  a  pre- 
existing adenomatous  or  cystic  goitre,  enucleation  of  these 
tumours  can,  of  course,  be  performed. 

Removal  of  a  portion  of  the  goitre  bv  the  operation  of 
"extirpation''  is  feasible,  and  has  been  frequently  performed. 
Much  difference  of  opinion  exists  as  to  the  value  of  this  proceeding. 

Those  who  believe  that  Graves's  disease  is  due  primarily  to 
an  affection  of  the  thyroid  gland,  and  especially  those  who  look 
upon  the  disease  as  being  due  to  a  hypersecretion  of  the  thyroid 
epithelium,  have  naturally  some  a  jjriori  grounds  for  believing 
that  removal  of  a  portion  of  the  gland  might  benefit  the  patient. 
Total  extirpation  of  the  gland  has  been  performed,  but  it  is 
agreed  by  all  that  this  is  neither  necessary  nor  desirable,  seeing 
that  very  serious  results  (cachexia  strumipriva)  follow  this  oper- 
ation, whether  performed  for  exophthalmic  or  for  any  other  kind 
of  goitre. 

The  operation  that  has  most  often  been  performed  is  removal 
of  one  half  of  the  gland. 

It  appears  that  good  results  have  in  some  cases  been  obtained 
by  this  operation.  On  the  other  hand,  it  must  be  admitted  that 
the  operation  is  an  extremely  serious  one.  The  mortality  of 
unilateral  extirpation  for  exophthalmic  goitre  is  far  higher  than 
is  that  of  the  same  operation  when  performed  for  simple  goitre. 

Valuable  information  on  this  point  has  been  afforded  by  Allen 
Starr,*  who  has  collected  from  various    sources  190  casesf  of 

*  "  On  the  nature  and  treatment  of  exophtlialniic  goitre  with  especial  refer- 
ence to  the  thyi'oid  theory  of  the  disease  and  to  the  treatment  by  thyroidec- 
tomy," Med.  News,  Philadelphia,  1896,  68,  p.  -121. 

f  All  these  operations  were  performed  in  or  before  1895.  These  cases,  how- 
ever, include  a  certain  number  of  operations,  such  as  ligature  of  the  thyi'oid 
arteries,  in  which  no  part  of  the  goitre  was  actually  removed. 


EXOPHTHALMIC    GOITRE.  189 

operations  upon  exophthalmic  goitre  ;  of  these  no  less  than  23 
ended  fatallv  immediately  after  the  operation.  This  mortality 
of  12  per  cent,  compares  most  unfavourablv  with  the  mortality 
of  3^  per  cent,  afforded  bv  Reverdin"s  statistics  of  extirpations 
of  simple   goitre. 

Sorgo"s  statistics*  embrace  174  operations  performed  in  the 
years  1884-96.  In  two  cases  the  result  was  not  known.  Of  the 
remaining  172  patients,  27  (15'2  per  cent.)  were  "much  im- 
proyed,"  62  (36  per  cent.)  were  "distinctly  improyed '" ;  [that 
is,  89  (51  "2  per  cent.)  were  improyed]  -±8  (27'9  per  cent.)  were 
"cured,""  11  (6"4  per  cent.)  were  not  improyed  or  were  made  worse; 
while  24  (13'9  per  cent.)  died  soon  after  the  operation.  It  is 
said  that  if  the  cases  of  so-called  primary  Grayes's  disease  are 
separated  from  those  of  secondary  disease,  the  statistics  are  not 
materially  altered. 

Mobius  considers  that  in  most  cases  "  the  operation  will  pro- 
bably result  in  comparatively  rapid  improyement,  but  that  it  is 
not  without  danger."  With  the  latter  part  of  this  opinion  I 
certainly  feel  disposed  to  agree. 

Even  in  the  hands  of  the  most  experienced  operators  upon 
goitre,  such  as  Kocher,  the  mortality  is  considerable.  It  would 
appear  that  Kocher  has  abandoned  the  operation  of  extirpation 
for  exophthalmic  goitre  in  favour  of  ligature  of  the  thyroid 
vessels.  It  is  not  that  the  operation  is  in  itself  more  difficult. 
But  the  patients  are  not  good  subjects  for  such  an  operation. 
They  are  especially  liable  to  die  from  shock  or  from  extreme 
rapidity  of  pulse.  For  these  reasons  I  have  myself  never 
performed  removal  of  an  undoubtedly  exophthalmic  goitre  and 
am  of  opinion  that  its  performance  should  as  a  rule  be  restricted 
to  those  rare  cases  in  which  there  is  serious  tracheal  stenosis, 
threatening  the  life  of  the  patient.  Even  in  these  cases  it 
seems  doubtful  whether  tracheotomy  is  not  sometimes  a  safer 
proceeding. 

The  operation  of  exothyropexij  has  been  performed  many 
times,  especially  in  France.  TTiis  operation  consists  in  cutting- 
down  upon  the  gland,  dislocating  it  through  the  wound  and 
then  leaving  it  exposed  to  the  air.  The  effect  of  the  operation 
is  to  cause  a  certain  amount  of  shrinking  of  the  gland.  The 
*  Quoted  by  Mobius.  hjc  cit.  p.  922. 


190  THE   THYROID   GLAND. 

risks  of  the  proceeding  and  the  extremely  unsightly  nature  of 
the  resulting  deformity  are,  in  the  absence  of  any  strong  proof 
of  its  efficacy,  sufficient  to  warrant  its  condemnation.* 

2.  Operations  upon  the  Thyroid  Vessels. — Ligature  of  the 
thyroid  vessels  has  often  been  performed  for  exophthalmic  goitre 
in  the  hope  that  cutting  ofp  the  blood  supply  will  cause  the  gland 
to  shrink  and  produce  less  colloid  secretion. 

Ligature  of  the  superior  thyroid  vessels  alone,  which  are 
usually  much  smaller  than  the  inferior,  is  an  easy  operation,  but 
does  not  cut  off  enough  of  the  blood-supply  to  be  of  any  real 
use.  Ligature  of  the  inferior  thyroid  vessels  on  one  or  both 
sides  adds  considerably  to  the  difficulty  and  severity  of  the 
operation.  I^igature  of  all  four  arteries  probably  entails  a  risk 
of  the  supervention  of  cachexia  strumipriva.  Ligature  of  both 
superior  thvroids  and  of  one  inferior  thyroid  appears  to  be  the 
best  operation  and  is  the  one  preferred  by  Kocher.  This 
operator  has  performed  ligature  of  the  thyroid  vessels  for 
exophthalmic  goitre  over  thirty  times. 

3.  Operations  upon  the  Cervical  Sympathetic  Nerve. — The 
operations  that  have  hitherto  been  performed  upon  the  cervical 
svmpathetic  nerve  include : 

(1)  Simple  section  of  the  nerve  (sympathicotomy  or  Jaboulay's 
operation). 

(2)  Partial  resection,  the  superior  cervical  ganglion  being- 
resected,  either  alone  or  together  with  the  nerve  trunk. 

(3)  Complete  and  bilateral  resection  of  the  whole  nerve  and 
all  its  ganglia. 

These  operations  appear  to  be  founded  partly  upon  the  view 
that  the  primary  seat  of  Graves's  disease  lies  in  the  cervical 
svmpathetic  nerves  or  ganglia,  and  partly  upon  the  widespread 
but  erroneous  idea  that  the  enlargement  of  the  thyroid  and  the 
exophthalmos  are  due  to  the  increased  vascularity  in  the  gland 
and  in  the  orbit  respectively.  There  is  no  doubt  that  there  is  a 
connection  between  exophthalmos  and  the  sympathetic,  but  it  is 
by  no  means  clear  that  the  exophthalmos  of  Graves's  disease  is 
dependent  upon  this  nerve. 

The  researches  of  Jessop  upon  the  action  of  cocaine  have 
shown  that  the  instillation  of  cocaine  into  the  eye  produced 
*  For  further  details  of  this  operation  see  chap.  xv.  p.  244. 


EXOPHTHALMIC   GOITRE.  191 

among  other  effects,  exophthalmos  and  enlargement  of  the 
palpebral  fissure.  It  has  further  been  shown  bv  Jessop  and  by 
Edmunds  that  previous  division  of  the  cervical  sympathetic 
prevented  the  occurrence  of  these  phenomena. 

Jaboulay  of  Lyons  appears  to  have  been  the  first  to  apply 
these  facts  to  the  treatment  of  exophthalmic  goitre  in  the 
human  subject. 

His  first  operation  was  performed  in  February  1896,  and  his 
example  was  rapidly  followed  by  others.  The  results  being, 
however,  not  so  good  as  had  been  anticipated,  a  further  step 
was  taken  and  in  August  1896  Jonnesco  of  Bucharest  excised 
the  superior  cervical  sympathetic  ganglion  together  with  part  of 
the  main  nerve  trunk.  This  operation  in  its  turn  appearing  to 
be  insufficient,  the  total  excision  of  the  whole  of  the  cervical 
sympathetic  including  its  ganglia  on  both  sides  of  the  neck  was 
introduced  and  is  at  the  present  time  advocated  by  Jonnesco 
and  others. 

Whether  the  theories  upon  which  these  sympathetic  operations 
are  based  be  right  or  wrong,  it  is  well  to  inquire  whether  the 
results  obtained  by  the  operations  are  sufficiently  good  to  justify 
their  performance. 

Boissou,  in  his  admirable  thesis*  on  the  subject,  has  collected 
twenty-seven  cases  of  operations  of  one  kind  or  another  upon  the 
sympathetic  nerve  for  the  cure  of  Graves's  disease.  These  cases 
include  nearly  all  the  published  and  some  hitherto  unpublished 
cases,  up  to  the  date  of  July  1898.  Full  details  of  nearly  all  the 
cases  are  given  in  his  essay. 

From  these  twenty-seven  cases,  four  must  be  deducted  since 
they  prove  nothing  and  are  valueless  for  our  purpose.  Eight  of 
the  remaining  cases  are  atypical  (cas  frustes)  and  should  be  put 
aside  as  inconclusive. 

Among  the  remaining  fifteen  cases  there  appear  to  have  been 
two  cases  of  cure,  six  of  "  marked  improvement,"  three  of  slight 
improvement,  one  of  failure  and  three  of  death. 

With  regard  to  the  eight  atypical  cases,  one  is  reported  to 
have  been  cured,  two  markedly  improved,  four  slightly  improved, 
while  one  was  a  failure. 

*  ••  Etude  critique  des  iuterventious  sur  le  sympathique  cervical  dans  la 
maladie  de  Basedow,"  Paris,  Henri  Jouve,  1898. 


192  THE    THYROID    GLAND. 

Among"  the  twentv-three  cases  there  were  thirteen  partial 
sympathectomies  (includino-  the  three  reported  cures  and  one 
death),  seven  total  sympathectomies  (with  two  deaths),  and  two 
sympathectomies  (with  no  cures  and  no  deaths). 

The  two  cases  of  cure  are  the  following,  both  of  which  occurred 
in  the  practice  of  Jonnesco  :  * 

1.  A  widow  aged  30  had  noticed  for  two  months  a  swelling  of  the 
thyroid  gland.  On  admission  there  was  some  exophthahnos  and  a 
pulse  of  110-120.  Graefe's  sign  was  not  present.  There  was  some 
trembling  of  the  upper  limbs  and  the  patient  was  in  a  nervous, 
excitable  condition.  On  August  5,  1896,  bilateral  resection  of 
the  cervical  sympathetic  was  performed,  but  the  inferior  ganglia 
were  not  removed.  The  wound  healed  by  first  intention  and  the 
patient  left  the  hospital  ten  days  after  the  operation.  The  imme- 
diate results  of  the  operation  do  not  appear  to  have  been  very 
striking.  The  jjulse  remained  at  120,  but  the  exophthalmos  dis- 
appeared. The  trembling  had  also  gone  when  the  patient  left  the 
hospital.  A  month  later  the  circumference  of  the  neck  had 
diminished  from  37  to  35  centimetres.  Fifteen  months  later  the 
general  condition  was  reported  to  be  excellent ;  there  was  no 
longer  any  goitre,  exophthalmos,  tachycardia,  or  trembling.  The 
pulse  rate  was  74-80. 

2.  A  girl  aged  l6  was  admitted  on  account  of  goitre,  exophthalmos, 
trembling,  and  a  rapid  pulse  (110-120).  On  August  21,  189^,  the 
whole  cervical  symj^athetic,  except  the  inferior  ganglion,  Avas 
resected  on  both  sides  of  the  neck.  The  Avound  healed  by  first 
intention  and  the  patient  left  the  hospital  nineteen  days  after  the 
operation.  The  exophthalmos  diminished  immediately,  but  the 
pulse  remained  at  110-120.  When  last  seen,  fifteen  months  after 
the  operation,  the  exophthalmos  and  tachycardia  had  entirely  dis- 
appeared, the  pulse  Avas  regular,  beating  at  90,  and  the  patient's 
general  condition  Avas  excellent. 

The  three  fatal  cases  described  by  Boissou  occurred  in  the 
practice  of  Jaboulay,  Faure  and  Peugniez  respectively .f 

1.  A  woman  aged  30  with  exophthalmic  goitre  of  tAvo  years 
duration.  Goitre,  exophthalmos,  tachycardia  and  trembling  Avere 
all  well  marked.  The  pulse  rate  was  128-155.  On  Nov.  24, 
1897,  three  centimetres  of  cervical  sympathetic  were  resected  on 

*  Keported  in  Boissou's  thesis  above-mentioned,  cases  xi.  andxii.  pp.  148-1. ■')4. 
f  Boissou,  loc.  c'tf.,  cases  s. ,  xyiii.  and  xxAii.  pp.  114,  175  and  206. 


EXOPHTHALMIC   GOITRE.  193 

each  side  of  the  neck.  On  one  side  the  superior  ganglion  was 
removed,  on  the  other  it  was  not.  After  the  operation  the  pulse 
rate  was  120.  On  the  following  day  the  temperature  rose  to 
104-5  and  the  pulse  became  bad.  On  the  next  day  blood-stained 
expectoration  and  vascularity  of  the  right  conjunctiva  were  noticed. 
The  exophthalmos  diminished.  In  the  next  few  days  the  pulse  rate 
was  90-105,  and  the  temperature  about  101^.  On  the  twelfth  day 
after  the  operation  the  patient  died.  The  post  mortem  showed 
congestion  of  the  base  of  the  right  lung. 

2.  A  woman  aged  24,  with  all  the  usual  symptoms  very  well 
marked.  The  whole  of  the  right  cervical  sympathetic,  including 
both  superior  and  inferior  ganglia,  were  removed  and  the  operator 
had  made  the  skin  incision  on  the  left  side  when  the  patient 
suddenly  died.  The  post  mortem  threw  no  light  on  the  cause  of 
death,  which  seems  to  have  been  attributed  to  the  chloro- 
form. 

3.  A  woman  aged  20  in  whom  exophthalmos,  tachycardia  and 
goiti'e  were  all  marked.  The  symptoms  had  lasted  about  four 
years.  Resection  of  the  whole  cervical  sympathetic  was  performed, 
first  on  the  left  side  then  on  the  right,  with  an  interval  of  twenty- 
three  days  between  the  two  operations.  After  the  first  operation  the 
exophthalmos  of  the  corresponding  side  diminished  considerably. 
The  tachycardia,  however,  did  not  alter,  the  pulse  remained  at  144. 
After  the  second  operation  the  pulse  dropped  to  128.  Both  wounds 
healed  quickly,  and  the  patient  left  the  hospital  apparently  slightly 
improved. 

The  improvement  did  not  last  very  long,  for  on  the  day  after  her 
discharge  from  the  hospital,  twenty-four  days  after  the  second 
operation,  she  complained  so  much  of  feebleness  and  pain  in  the 
precordial  region  that  she  took  to  her  bed  and  never  again  left  it. 
Violent  pain  in  the  head  and  eyes,  vomiting  and  extreme  emaciation 
now  became  prominent  symptoiTis.  A  week  after  leaving  the 
hospital  the  exophthalmos  was  very  marked,  but  the  eyelids  could 
still  be  closed.  Soon  the  exophthalmos  was  so  extreme  that  the 
patient  became  completely  blind  in  both  eyes,  the  left  eyeball 
ulcerated  and  then  collapsed,  with  discharge  of  the  crystalline  lens. 
Finally  the  patient  died  comatose  on  the  fiftieth  day  after  the 
operation. 

A  careful  study  of  the  cases  which  are  reported  to  have  been 
"improved"  does  not  seem  to  be  at  all  convincing.  Sometimes 
one  symptom,  sometimes  another  is  said  to  have  been  alleviated. 
Sometimes   the   beneficial   effect   is   said   to   have  been   noticed 


194  THE   THYROID    GLAND. 

immediately  after  the  operation,  more  often  the  ameHoration 
has  occurred  only  after  a  lapse  of  weeks  or  months. 

The  cases  in  which  improvement  is  most  likely  to  occur  seem 
to  be  those  atypical  cases  to  which  the  tevxw  formes  Ji'ustes  is 
applied  by  the  French.  In  many  of  these  cases,  however,  grave 
doubts  exist  as  to  the  correctness  of  the  diagnosis.  For  statistical 
purposes,  it  is  best  to  omit  such  cases  altogether  from  our  con- 
sideration. Certainly  it  is  not  right  to  include  them  among 
the  typical  cases,  the  diagnosis  of  which  shotdd  be  a  matter  of 
little  or  no  difficulty,  and  from  which  alone  conclusions  of  value 
can  be  deduced. 

4.  Operations  upon  Distant  Parts  of  the  Body. — Many  years 
ago  it  was  noticed  that  the  removal  of  a  polypus  from  the  nose 
of  a  patient  suffering  from  Graves's  disease  was  followed  by  an 
amelioration  of  the  symptoms  of  the  latter  disease.  The  same 
sequence  of  events  has  been  noticed  after  operations  on  other 
parts  of  the  bodv.  Boissou  *  has  collected  no  less  than  seventy- 
three  cases  of  Graves's  disease  in  which  improvement  or  cure 
had  followed  an  operation  upon  some  distant  part  of  the  body 
such  as  the  nasal  fossae,  the  genito-urinary  organs,  abdomen,  etc. 

I  have  myself,  however,  had  no  personal  experience  of  such 
cases. 

Prognosis. — In  considering  the  advisability  of  a  surgical  opera- 
tion for  any  disease,  it  is  well  to  ask  what  would  be  the  course 
of  that  disease  if  no  operation  at  all  were  performed.  Now,  in 
the  case  of  exophthalmic  goitre  the  prognosis,  if  the  disease  be 
not  treated  by  operation,  is  by  no  means  wholly  bad.  Although 
in  a  few  cases  the  disease  ends  speedily  in  death,  yet  such  a 
termination  is  the  exception  rather  than  the  rule. 

The  careful  inquiries  that  have  been  made  by  Williamson  ,j" 
of  Manchester,  supplemented  by  those  of  Ord  and  Hector  Mac- 
kenzie, have  put  us  in  possession  of  valuable  information  as  to 

*  43  cases  of  Jouiu.  5  of  Stocker,  -t  of  Teilliaber,  3  of  Van  der  Lenden,  3  of 
Fedei-n.  2  of  Leflaive,  2  of  Odeije,  2  of  Bouilly,  and  those  of  Hack.  Hoffmann, 
Fraenkel,  Gottstein,  Muschold,  Picque,  Turgis,  Doleris,  and  Berger.  quoted  by 
Pierre  Boissou  in  his  "  Etude  critique  des  interventions  sur  le  sympathique 
cervical  dans  la  maladie  de  Basedow."  Paris.  1898.  p.  15. 

t  "Eemarks  on  Prognosis  in  Exojjhthalniic  goitre,"  hy  E.  T.  Williamson, 
JBrlt.  Med.  Jum-n.,  Nov.  7,  1896,  p.  1373. 


PLXOPHTHALMIC   GOITRE. 


190 


the  ultimate  result  of  a  large  number  of  cases,  none  of  which 
were  treated  by  operation.  Taking  into  consideration  only 
those  cases  which  ended  either  in  death  or  recovery,  or  which 
had  been  under  observation  for  at  least  five  years,  the  figures  of 
the  two  sets  of  observers  *  are  as  follows  : 


EESULT  IX  FIFTY-SEVEX  CASES. 


Or 


Fatal  termination     . . . 
Recovery  complete  . . . 
Recovery  almost  complete 
Improvement  considerable 
Improvement  slight 
In  statu  quo  ... 
Alive,    but    exact    condition 
not  known 


ckenzie 

Williamson 

Tota 

8 

6 

14 

5 

5 

10 

9 

2 

11 

9 

4 

13 

1 

S 

4 

1 

3 

4 

Conclusions. — Reviewing  the  whole  subject  of  the  operative 
treatment  of  exophthalmic  goitre,  it  seems  to  me  that  it  may 
reasonably  be  doubted  whether  surgical  treatment  is  not  on  the 
whole  worse  than  useless. 

For  it  must  not  be  forgotten  that  in  this  disease  there  is 
naturally  a  strong  tendency  towards  recovery.  Many  patients 
who  do  not  recover  completely,  nevertheless  improve  greatly 
without  operative  treatment  of  any  kind. 

None  of  the  operations  that  have  hitherto  been  practised 
upon  the  gland,  the  thyroid  vessels  or  the  sympathetic  are  free 
from  risk.  Actual  proof  that  any  of  them  really  cure  the 
disease  is  at  present  wanting.  The  sympathetic  operation, 
although  it  may,  and  probably  does  to  a  slight  extent,  diminish 
the  exophthalmos,  does  not  usually  cure  it  completely,  and  may 
be  followed  by  very  serious  results,  such  as  inflammation  of  the 
eye  and  even  blindness. 

The  larger  operations  upon  the  gland  itself,  such  as  extirpa- 
tion, are  attended  with  so  much  danger  as  to  make  them  un- 
desirable, unless  it  can  be  shown  that  the  results  are  sufficiently 
good  to  justify  the  risks.     At  present  this  has  not  been  done. 


Given  in  Clifford  Allhutt's  "  System  of  Medicine,"  1897,  vol.  iv,  p.  .501. 


lf)6  THK   THYROID    (xLAND. 

AVith  regard  to  ligature  of  the  thyroid  vessels,  it  still  seems 
to  me  doubtful  whether  this  proceeding  is  followed  by  cure 
sufficiently  often  to  justify  its  performance.  There  seems  to  be 
no  doubt  that  if  any  of  the  above  operations  are  undertaken  by 
the  surgeon,  thev  should  be  performed  in  most  cases  without 
general  anaesthesia,  and  that  they  should  be  performed  with  as 
little  disturbance  as  possible  to  the  surrounding  parts. 


CHAPTEK   XIII. 

MALIGNANT  DISEASE  AND  ITS  TREATMENT* 

Aiiects  both  uormal  and  goitrous  thyroid — Age — Sex — ^^'aiueties — Sar- 
coma and  carcinoma — Eehitive  frequencj" — Spuptoms  and  diagnosis — 
Infiltration  of  neighbouring  parts — Skin  rarely  involved — Duration  of 
the  disease — Mode  of  death — Unusual  forms  of  malignant  disease — 
••  Malignant  adenoma  " — Papillif erous  cyst — Treatment — Extirpation 
Difficulties  and  dangers — Often  incomplete — Results  of  operations — 
Eecurrence — Statistics — Slowly  growing  forms — Palliative  treatment — 
Partial  removal — Simple  incision — Tracheotomy — Difficulties — Danger 
of  sepsis — Treatment  of  dysphagia  and  pain — Conclusions. 

Maxigxaxt  disease  of  the  thyroid  gland  is  in  this  country  a 
somewhat  rare  affection.  It  is  fortunate  that  it  is  rare,  since  in 
the  stage  at  which  it  is  usually  seen  by  operative  surgeons  it  is 
seldom  amenable  to  surgical  treatment. 

The  disease  may  occur  in  a  gland  that  has  previously  been 
normal,  but  it  is  much  more  prone  to  affect  one  that  has  already 
been  the  seat  of  innocent  goitre.  This  is  doubtless  the  reason 
why  the  disease  is  much  more  commonly  seen  in  localities 
where  ordinary  goitre  is  prevalent.  E^"en  in  cases  in  which 
there  is  no  history  of  pre-existing  goitre  it  will  often  be  found, 
upon  examination  after  removal,  that  the  tumour  contains 
cysts,  points  of  calcification,  or  some  similar  evidence  of 
former  disease.  In  several  cases,  however,  which  have  come 
under  my  own  notice,  or  which  I  have  examined  in  museums, 
evidence  of  the  previous  existence  of  a  goitre  has  been  wholly 
absent. 

Age  and  Sex. — The  disease  is  essentially  one  of  advanced  life, 
being  rare  below  the  age  of  forty.  Out  of  thirty-four  specimens 
of  malignant  disease  in  the  London  museums,  in  which  the  age 

*  Most  of  tills  chapter  has  akeady  been  published  in  the  chapter  on  the 
th\Toid  contributed  b}-  me  to  the  recently  f)ublished  edition  of  Mr.  Butlin"s 
••  Operative  Surgerj'  of  Malignant  Disease.'' 


198  THE   THYROID    GLAND. 

of  the  patient  is  stated,  I  have  fouml  oulv  three  in  which  the 
age  was  below  thirty-nine,  and  of  these,  one  is  a  somewhat  doubt- 
ful cono;enital  sarcoma  in  an  infant ;  another  is  from  a  bov  ao;ed 
three,  and  it  is  open  to  doubt  whether  the  growth,  described  as 
a  round-celled  sarcoma,  was  not  secondary  to  disease  of  the 
abdomen.  The  third  specimen  is  in  the  Roval  Free  ]\Iuseum, 
and  is  from  a  patient  of  my  own,  aged  25,  depicted  in  Fig.  77. 
Here  and  there  in  surgical  literature  are  found  cases  in  which 
the  disease  occurred  in  children  or  voung  adults,  but  certainly  in 
the  great  majority  of  cases  the  patients  have  attained  at  least 
the  age  of  forty. 

Among  fifty  cases  of  undoubted  malignant  disease  that  have 
been  published  since  1884,  I  find  onlv  eight  in  which  the  age 
was  below  forty.  In  no  less  than  twenty-four  of  these  cases  the 
age  was  fifty  or  more  :  of  these,  twelve  had  attained  the  age  of 
sixty. 

As  regards  the  frequency  with  \\hich  the  disease  affects  the 
two  sexes  there  is  not  much  difference.  Some  observers  have 
found  that  males  were  affected  rather  more  often  than  females. 
I\Iy  own  statistics  show  that  of  the  fifty  patients  above-mentioned 
twenty-seven  were  women  ;  among  thirty-nine  specimens  in  the 
London  museuiiis,  seventeen  are  from  male  and  twenty-two  from 
female  patients ;  a  very  small  number  of  cases  overlap,  and 
occur  in  both  sets  of  figures.  Bergeat  says  that  of  fifty-five 
cases  seen  at  Tubingen  between  1883  and  1894,  twenty-three 
were  men  and  tweutv-nine  women,  but  the  diagnosis  was  not  in 
all  cases  verified. 

Varieties. — Both  carcinoma  and  sarcoma  occur  in  the  thyroid 
o'land,  the  former  beino;  usually  of  the  alveolar  form  with  cubical 
cells,  the  latter  either  spindle-  or  round-celled.  Various 
other  rare  varieties  have  occasionally  been  described  but  are 
not  of  sufficient  importance  to  require  further  consideration 
here. 

It  is  exceedingly  difficult  to  arrive  at  a  definite  conclusion 
as  to  the  relative  fi-equency  of  sarcoma  and  carcinoma. 
!Most  writers  have  asserted  that  carcinoma  is  a  good  deal  more 
common  than  sarcoma.  Thus  Kaufmann"'  among  fourteen  cases 
examined  microscopically  by   him   in   S\\itzerland,  found    that 

^  ■•  Die  Struma  Malisrna."  Dciii-.^rh.  Zeitsrh r.f.   Chh-..  187ii.  xi.  4nl. 


MALIGNANT   DISEASE   AND   ITS   TREATMENT.     199 

eleven  Avere  carcinoma  and  only  three  were  sarcoma ;  and 
subsequently  he  published  six  more  cases  all  of  Avhich  were 
carcinoma. 

Orcel,  in  his  excellent  thesis,*  gives  details  of  sixteen  cases  of 
malignant  disease  observed  at  Lyons,  a  place  where  endemic 
goitre  is  frequently  seen.  Rejecting  one  of  these,  in  which  the 
proof  of  malignancy  does  not  appear  to  be  convincing  and 
omitting  five  others  which,  although  undoubtedly  malignant, 
do  not  clearly  indicate  whether  the  disease  was  sarcoma  or 
carcinoma,  there  remain  ten  cases  ;  of  these  five  Avere  sarcoma 
and  five  carcinoma. 

Of  fifty-four  specimens  in  London  museums,  twenty  are 
sarcoma  and  thirteen  are  carcinoma,  while  of  twenty-one,  owing 
to  want  of  proper  microscopical  examination,  it  is  impossible  to 
express  a  definite  opinion.  Among  fifty  undoubted  cases  found 
in  literature  published  since  1884  (including  Orceins  ten  cases)  I 
find  twenty-six  sarcomata  and  twenty-four  carcinomata.  These 
last  two  sets  of  figures,  however,  probably  do  not  represent  the 
true  proportions,  since  the  rapidly  growing  form  of  sarcoma  is  a 
more  striking  affection  than  the  ordinary  form  of  carcinoma,  and 
is,  therefore,  more  likely  to  find  its  way  into  museums  and  into 
literature. 

In  compiling  the  above  statistics,  I  have  felt  obliged  to  reject 
a  very  large  number  of  cases  which  in  all  probability  were 
malignant,  because  the  proof  of  this  was  wanting.  Those 
cases  only  have  been  accepted  as  genuine  in  which  such  proof 
was  clearly  afforded  either  by  accurate  microscopical  exami- 
nation or  by  evidence  of  local  infiltration,  or  of  secondary 
deposits. 

The  difficulties  which  surround  the  whole  subject  are  consider- 
able, since  cases  are  frequently  met  with  both  in  literature  and 
in  museums  in  which  an  obvious  sarcoma  is  described  as  car- 
cinoma and  vice  versa.  Instances  are  not  unknown  of  simple 
adenoma  being  described  as  carcinoma,  while  obviously  malig- 
nant infiltrating  tumours  have  been  pronounced  to  be  adenomata. 
Even  those  who  have  had  large  experience  in  the  microscopic 
examination  of  thyroid  tumours  will  admit  that  it  is  often 
difficult  to  say  where  adenoma  ends  and  carcinoma  begins. 
*  "  Contribution  a  Tetude  du  cancer  du  corps  thyroide,"  Lyons,  1889. 


200 


J'HK   THYROID    GLAND. 


.=  c 

a  . 

o  = 

o  .- 


MALIGNANT   DISEASE    AND    ITS    TREATMENT.     201 

Chronic  inflammation  has  before  now  been  mistaken  for  sarcoma, 
as  Tailhefer  and  Riedel  have  shown. 

Symptoms  and  Diagnosis. — CHnieally,  it  is  very  difficult  to 
distinguish  between  sarcoma  and  carcinoma.  In  many  cases  it 
is  not  possible  to  do  more  than  guess  at  the  probable  histological 
nature  of  the  malignant  growth.  I  shall,  therefore,  treat  of 
them  together,  merely  prefacing  my  remarks  by  saying  that 
if  the  tumour  has  grown  very  rapidly,  and  is  limited  to 
one  lobe  of  the  gland,  the  disease  is  more  likely  to  be 
sarcoma  ;  while  if  the  affection,  at  a  comparatively  early  stage, 
involves  both  lobes  and  pursues  a  somewhat  slow  course, 
it  is  not  unlikely  that  it  will  prove  to  be  carcinoma.  Ex- 
ceptions to  both  these  rules  are,  however,  by  no  means 
uncommon. 

In  its  earliest  stages,  while  the  growth  is  still  confined  within 
the  capsule  of  the  gland,  there  are  no  means  by  which  Ave  can 
make  a  certain  diagnosis  of  malignant  disease.  When,  hozcever, 
in  the  thyroid  gland  of  a  person  over  forty,  a  tumour  appears 
which  is  hard,  which  steadily  and  rapidly  increases  in  size,  and 
which  is  not  of  an  inflammatory  natiwe,  the  malignancy  of 
such  a  tumour  shoidd  he  strongly  suspected.  If,  moreover,  the 
surface  of  the  tumour  is  irregular  and  bossy,*  and  if  there  is 
likewise  dysphagia  and  pain  in  the  neck,  shooting  up  to  the 
side  of  the  head,  or  to  the  shoulders,  then  the  diagnosis  becomes 
almost  a  certainty.  It  is  of  the  utmost  importance  that  the 
diagnosis  should,  if  possible,  be  made  at  an  early  period,  since 
it  is  then  alone  that  operative  treatment  can  be  adopted  with  a 
reasonable  prospect  of  success.  A  little  later,  when  the  growth 
has  penetrated  the  capsule,  and  begun  to  involve  surrounding 
structures,  various  other  signs  appear  which  make  the  diag- 
nosis much  less  difficult.  The  vocal  cord  on  the  corresponding 
side  often  becomes  paralysed,  a  condition  rarely  seen  with 
innocent  goitre.  Involvement  of  the  trachea,  Avith  pene- 
tration of  its  lumen  by  the  growth,  is  very  common,  and  is 
abundantly  illustrated  by  specimens  in  museums.  {See  Figs. 
78  and  80.) 

This  penetration  of  the  interior  of  the  trachea  is  most  common 
at  a  point  about  half  an  inch  below  the  cricoid,  and  often  takes 

*  Figs.  75  aud  76  show  well  the  bossv  nature  of  a  malignant  tliyroid  tumour. 


202 


THE   THYROID    GLAND. 


the  form  of  a  small  prominent,  sometimes  even  pedunculated, 
button  of  growth.  It  occurs  both  in  sarcoma  and  carcinoma. 
Occasionally,  a  considerable  length  of  the  tracheal  mucous  mem- 
brane is  involved,  as  in  the  specimen  depicted  in  Fig.  80.* 
Involvement   of    the   muscular    wall   of    the    pharynx   is   very 


I'lG.  77. — Spiiidk'-CL'llua  Sarcoma  of  the  left  Lobe  of  the  Tli.vroid.  The 
position  of  the  hiryus  is  sliowu  by  a  slight  swelling  more  than  one 
inch  to  the  right  of  the  middle  line.  Trom  a  patient,  aged  2-5,  who  had 
fli'st  noticed  the  lump  in  his  neck  three  months  before  the  photograph 
was  taken.  The  growth  snrrotiiidcd  the  carotid  artery  and  was  too 
extensile  to  permit  of  any  attempt  at  removal.  Tracheotomy  soon 
became  necessary.    {See  Royal  Free  Hosp.  Mns.  Xo.  xxii.  54.) 

common,  but  actual  penetration  of  its  mucous  membrane  is 
rare.  There  are  but  two  specimens  of  this  latter  condition  in 
the  London   museums.     Kaufmann,   in   the  cases  collected  by 

*  From  a  specimen  in  the  Mu^ieum  of  the  Eoy.  Coll.  of  Surg.  No.  2907.  For 
other  specimens  of  penetration  of  trachea  or  larynx,  see  St.  Bart.  Hosp.  Mus. 
No.  23190  ;  St.  Thos.  Hosp.  Mus.  Nos.  1470A  and  1472  ;  Westm.  Hosp.  Mus. 
No.  fil2. 


MALIGNANT   DISEASE   AND    ITS   TREATMENT.     203 

him,  found  but  one  instance  in  which  the  mucous  membrane  was 
penetrated.  Displacement,  curving,  twisting  and  flattening  of 
the  trachea,  although  common  enough  in  cases  of  malignant 
disease  of  the  thyroid  are  not  more  characteristic  of  malignant 


Tig.  78. — Spindle -cellod  Sarcoma  of  the  'Diyi'oid,  showing-  the  manner 
iu  which  the  "TOfltli  h;is  extended  behind  tlie  a«opli;igus  and  between 
it  and  the  trachea,  a.  Larynx  laid  open  from  behind,  b.  Trachea 
surrounded  and  compressed  by  tumour,  c.  Remains  of  tliyroid  tissue 
more  or  less  healthy,  d.  Right  lobe  of  thyroid  infiltrated  with  sarcoma. 
E.  Sarcoma  extending-  between  tracliea  and  oesophagus  (f).  g  and  h. 
Riglit  and  left  carotid  arteries  surrounded  by  gTowth.  i.  Aorta,  k. 
Tracheotomy  wound.  (See  Appendix,  Case  113,  p.  352,  and  Roy.  Free 
Hosp.  Mus.  No.  xxii.  55.)     (8edu.ced  ^.) 

than  of  innocent  goitre ;  indeed,  the  tendency  of  the  former  to 
infilti-ate,  rather  than  to  push  aside,  causes  the  displacement  or 
deformity  of  the  trachea  to  be  less  marked. 

On  the  outer  side,  the  growth   tends  to  become   adherent  to 
the  carotid   artery  and  internal  jugular  vein.     The  relation  of 


-204 


THE   THYROID    GLAND. 


the  carotid  to  the  tumour  may  afford  valuable  evidence  of 
malignancy.  An  innocent  goitre  in  its  growth  usually  displaces 
the  artery,  outwards  and  backwards  ;  a  malignant  tumour  tends 
to  infiltrate,  to  overlap  and  surround  it,  without  causing  so 
much  displacement.  The  artery  can  often  be  traced  by  its 
pulsation,  running  as  far  as  the  tumour,  into  the  interior  of 
which  it  seems  to  disappear.  Paralysis  of  the  sympathetic, 
shown  by  a  contracted  pupil  and  narrow  palpebral  fissure,  is  not 
uncommon.     {See  Fig;  81.) 


Fig.  79. — Microscopical  section  of  a  Careinoraa  attacking-  an  old  ooitre 
wliich  has  also  nndergone  mnch  fibroid  degeneration.     (  x  130  diam.; 


Fixity  of  the  tumour  is  an  important  and  a  very  bad  sign. 
It  is  well  to  bear  in  mind  that  a  malignant  tumour  that  has  not 
become  fixed  to  such  immovable  structures  as  the  sternum, 
clavicle,  vertebrae,  or  the  larger  muscles  of  the  neck,  may  follow 
the  movements  of  the  larynx  and  trachea  with  tolerable  freedom 
and  yet  may  be  hopelessly  incorporated  with  the  latter,  or  with 
the  wall  of  the  pharynx.  Many  a  time  has  an  operator,  deceived 
by  this  apparently  free  mobility  of  the  tumour,  been  led  to 
undertake  an  operation  for  its  removal,  only  to  find,  when  too 
late,  that  the  adhesions  on  the  inner  side  were  so  extensive  that 
complete  removal  was  impossible. 


MALIGNANT   DISEASE   AND   ITS    TREATMENT.     205 

Involvement  of  skin  and  of  lymph  glands  afford  but  little 
help  in  the  diagnosis.  The  skin  is  seldom  involved,  even  in  late 
stages,  except  in  those  cases  in  which  the  growth  has  been  punc- 
tured or  incised. 

Exceptionally,  spontaneous  ulceration  of  the  skin  takes  place 
and  may  be  the  immediate  cause  of  death,  as  in  the  following 
case  : 

Harriet  F ^aged  53,  was  admitted  to  the  Royal  Free  Hospital 

under  my  care  on  March  2,  1899-  Since  childhood  she  had  had  a 
swelling  in  the  neck,  as  lai'ge  as  a  walnut.  It  had  never  caused  her 
any  trouble  until  November  1898,  when  it  suddenly  began  to  grow. 
It  continued  to  increase  steadily,  but  gave  her  no  pain  and  caused 
little  or  no  trouble  in  breathing  or  swallowing. 

The  condition  on  admission  is  shown  in  Figs.  15  and  76.  A  large, 
hard,  irregular,  prominent  tumour  occupied  the  front  of  the  neck 
and  involved  both  lobes  of  the  thyroid  gland.  The  carotid  could  be 
felt  indistinctly  on  the  right  side,  not  at  all  on  the  left.  The  diag- 
nosis of  malignant  disease  was  obvious,  and  owing  to  the  fixity  and 
extent  of  the  tumour,  operation  for  its  removal  was  out  of  the 
question.  On  March  12,  she  returned  to  her  home,  being  told  to 
come  up  again  if  her  breathing  gave  her  trouble.  In  April  she  was 
seen  again.  She  was  much  thinner  and  weaker,  and  the  tumour 
had  grown  considerably,  but  there  was  very  little  dyspnoea.  The 
skin  over  the  tumour  had  recently  ulcerated.  The  tumour  grew  to 
a  very  lai*ge  size,  the  ulceration  extended  and  was  accompanied  by 
very  foul  discharge.  The  patient  gradually  sank  and  died  at  home 
on  July  7,  1 899^  of  sepsis  and  exhaustion.  Dyspnoea  never  became 
sufficiently  bad  to  call  for  tracheotomy.  The  post  mortem  showed  a 
spindle-celled  sarcoma.* 

Out  of  some  thirty  cases  that  have  come  under  my  own 
notice  during  life,  there  was  not  a  single  one  in  which  affection 
of  glands  afforded  any  material  help  in  the  diagnosis.  By  the 
time  that  enlargement  of  the  glands  can  be  detected,  the  nature 
of  the  disease  is  usually  sufficiently  obvious ;  it  must  be  remem- 
bered that  the  glands  that  first  become  affected  are  usually 
very  deeply  seated,  at  the  root  of  the  neck,  or  behind  the 
sternum,  where  their  detection  is  well  nigh  impossible.  I  have 
also  been  very  much  struck  by  the  number  of  cases,  especially 

*  The  tumour  is  uow  iu  the  Royal  Free  Ho -p.  Mus.'No.  xxii.  53. 


206 


THK   THYROID   GLAND. 


of  sarcoma,  in  museums,  in  literature,  and  in  my  own  practice, 
in  which  affection  of  lymphatic  olands  was  wholly  absent,  even 
in  the  latest  stages  of  the  disease. 

Expectoration  of  blood  is  an  unusual  symptom ;  it  generally 

occurs  late  and  is  of  grave 
import,  indicating  probable 
penetration  of  the  trachea,  or, 
possibly,  secondary  growth  in 
the  lungs.  Occasionally,  it 
would  seem  to  be  a  com- 
paratively early  sign.  In  a 
case  of  carcinoma,  recorded 
by  Mr.  Shattock,  severe  htie- 
moptysis  occurred  ten  months 
before  death,  and  seems  to 
have  been  one  of  the  first 
symptoms.* 

The  course  of  malignant 
disease  of  the  thyroid  is  usually 
very  rapid.  Rose,  of  Berlin, 
has  estimated  that  theextreme 
limits  of  its  duration  are  nine 
weeks  and  eighteen  months, 
and  in  the  main  he  is  certainly 
correct.  Many  cases  run  their 
whole  course  within  six 
months. 

One  of  the  shortest  cases 
that  I  have  myself  seen  was 
that  of  a  sarcomatous  tumour 
in  a  gentleman,  aged  68,  under  the  care  of  Mr.  Edgar  Willett. 
When  I  first  saw  the  patient,  the  tumour  had  been  noticed  only 
four  weeks.  It  was  already  «o  fixed  as  to  be  hopelessly 
irremovable.  No  operation  of  any  kind  was  attempted ;  the 
disease  made  rapid  progress,  speedily  involved  the  lungs  with 
secondary  deposits,  and  death  occurred  within  three  months  from 
the  time  of  the  first  appearance  of  the  tumour. 

The  case  depicted  in  Fig.  77  (p.  202)  also  ran  a  very  rapid 
■  *  St.  Thos.  Hosp.  Mu^.  No.  1472. 


Fig.  80. — Vcvticiil  Mediuu  Section'  tliroiii;ii 
Larynx,  Trachea,  Thyroid  Gland,  &c., 
showiu.o-  malignant  disease  fungating'  into 
the  interior  of  the  trachea  in  its  upper  two- 
thirds.  (From  a  specimen  in  the  Key. 
Coll.  of  Surg.  Xo.  2907.) 


MALIGNANT   DISEASE   AND    ITS   TREATMENT.     207 

course  and  is  further  remarkable  for  the  unusual  youth  of  the 
patient : 

Charles    K ,    aged    25,  was   admitted  into    the    Royal    Free 

Hospital  under  my  care  in  July  18,  1899:,  on  account  of  the  tumour 
shown  in  the  photograph. 

Three  months  previously  he  had  first  noticed  a  slight  swelling  on 
the  left  side  of  the  neck.  It  gave  him  but  little  trouble  and  he 
paid  no  attention  to  it  until  a  fortnight  before  admission,  when  it 
began  to  grow  rapidly.  Slight  dyspnoea,  dysphagia,  and  huskiness 
of  voice  were  then  noticed  for  the  first  time. 

On  admission,  a  hard  irregular  tumour,  some  four  inches  in 
diameter,  occupied  the  left  side  of  the  lower  part  of  the  neck, 
displacing  the  larynx  and  trachea  far  to  the  right.  The  left  carotid 
artery  was  completely  buried  in  the  tumour  and  the  left  vocal  cord 
was  paralysed.  The  tumour,  which  was  obviously  malignant,  was 
hopelessly  irremovable.  The  patient  became  rapidly  worse,  dysp- 
noea, dysphagia,  and  pain  in  the  left  arm  and  shoulder  became 
prominent  symptoms.  On  July  28,  an  unusually  severe  attack  of 
dyspnoea  necessitated  tracheotomy.  This  gave  considerable  relief 
for  a  few  weeks,  but  the  patient  gradually  succumbed  and  died  on 
August  30,  a  little  more  than  four  months  after  the  onset  of  tlae 
disease.  The  immediate  cause  of  death  was  haemorrhage  from  the 
trachea.  The  post  mortem  showed  a  spindle-celled  sarcoma  of  the 
left  lobe,  with  extensive  involvement  of  the  trachea  and  pharynx. 
There  were  no  secondary  growths  anywhere. 

On  the  other  hand,  there  is  no  doubt  that  many  cases  last 
considerably  longer  than  eighteen  months.  I  have  seen  a  ease 
in  which  the  disease  had  already  lasted  more  than  two  years, 
the  tumour,  having  in  that  time,  attained  the  dimensions  of  an 
emu's  egg.  This  patient  died  four  months  later ;  no  operation 
was  performed. 

In  all  these  cases  there  had  been,  apparently,  no  pre- 
existing goitre,  so  that  the  onset  of  the  malignant  disease  could 
be  fairly  accurately  defined.  In  the  more  common  cases  in 
which  malignancy  is  engrafted  upon  innocent  goitre,  it  is  often 
difficult  to  say  at  w  hat  date  malignancy  began,  especially  if  the 
goitre  is  a  large  one.  Such  patients  often  first  present  them- 
selves for  advice  when  the  tumour  has  already  penetrated  the 
capsule  and  begun  to  cause  urgent  symptoms.  I  am  inclined 
to  think  that  in  some  few  of  these  cases  the  malignant  tumour 


208 


THE    THYROID   GLAND. 


may  really  have  existed  for  several  years,  although  in  the  great 
maiority  of  instances,  the  duration  is  probably  a  matter  of 
months  rather  than  of  years. 

Death  is  usually  caused  both  in  sarcoma  and  in  carcinoma  by 
the  extension  of  the  primary  growth  to  the  air  passages.     The 


Fio.  81. — Spiadlc-celletl  SarCOma  of  the  Tliyroid,  with  Paralysis  of  the 
riglit  syuapathetic  nerve  (shown  hy  tlie  narrow  palpebral  fissure  and 
contracted  pupil).  (From  an  ontiiatient  seen  at  St.  Bart.  Hosp.)  (See 
p.  213.) 

mechanical  obstruction  of  the  trachea  thus  produced  may  cause 
fatal  dyspnoea.  Ulceration  into  the  trachea  may  set  up  septic 
processes  in  the  tumour  which  rapidly  lead  to  the  death  of  the 
patient.  Bronchitis  or  pneumonia,  septic  in  origin,  is  fre- 
quently the  immediate  cause  of  death,  especially  if  tracheotomy 
has  been  performed.     Penetration  of  the  numerous  veins  in  and 


MALIGNANT   DISEASE   AND   ITS   TREATMENT.     209 

around  the  tumour,  especially  in  the  case  of  sarcoma,  frequently 
leads  to  the  occurrence  of  secondary  o-rowths  in  the  luno-s. 
Secondary  g-rowths  in  more  distant  yjscera  may  occur:  the  bones 
especially  are  liable  to  become  the  seat  of  secondary  carcinoma- 


FiG.  82. — liU-ge,  soft,  aud  very  vasciilai-  Malignant  Tiiniour  of  the  ThyroiJ. 
The  patient  died  at  home  of  suffocation  a  iew  months  later.  (Seen  at 
St.  Bart.  Hosp.  in  1886.) 

tous  growths.  These  secondary  growths  in  bone  have  a  remark- 
able tendency  to  reproduce  the  structure  of  the  thyroid  gland 
wdth  its  epithelial  yesicles  containing  colloid  matter.  In  some 
cases  the  resemblance  between  these  secondary  growths  and  the 
normal  gland  is  singularly  close. 

Sudden  haemorrhage  into  the  softened  interior  of  the  growth 
may  be  mentioned  as  an  occasional  cause  of  death. 


210 


THE   THYROID    GLAND. 


s  ^ 


q  a 


P4^ 


MALIGNANT   DISEASE   AND    ITS   TREATMENT.     211 

It  is  well  also  to  remember  that  in  the  later  stages  oedema  of 
the  glottis  may  supervene  very  rapidly,  and  be  the  immediate 
cause  of  death. 

A  few  words  may  be  said  about  certain  forms  of  malignant 
disease  -whicli  deviate  from  the  ordinary  type. 

Instead  of  being  hard,  the  tumour  may  present  itself  in  the 
form  of  a  soft  swelling  which  is  then  easily  mistaken  for  a  cyst 
or  for  an  inflammatory  swelling.  There  are  cases  in  which  the 
whole  gland  becomes  the  seat  of  a  soft  rapidly  growing  tumour. 
Such  cases,  when  occurring  in  young  subjects,  may  be  mistaken 
for  the  common  rapidly  growing  parenchymatous  goitre  of 
adolescents.  Cases  have  been  recorded  by  Boeckel  and  Tillaux, 
in  which  sarcomatous  tumours  have  given  rise  to  many  of  the 
symptoms  of  exophthalmic  goitre,  for  which  indeed  they  were 
mistaken. 

There  are,  moreover,  forms  of  malignant  tumour  which  must 
be  classed  among  the  carcinomata,  although  clinically  their 
course  is  very  different  from  that  of  the  ordinary  carcinoma.  I 
refer  to  the  so-called  "  malignant  adenomata,""  and  to  the 
papuliferous  cystic  tumours.  The  former  appear  to  occupy  an 
intermediate  position  between  innocent  tumours  and  the  more 
typical  carcinomata.  In  general  appearance  these  tumours  may 
closely  resemble  the  innocent  adenomata,  but  differ  from  them 
in  possessing  a  tendency  to  recur  after  removal,  and  to  dis- 
seminate. From  their  rarity  they  are  of  comparatively  little 
importance. 

Papuliferous  cystic  tumours,  although  rare,  are  of  some 
importance.  They  grow  slowly,  and  exhibit  but  a  low  degree 
of  malignancy.  They  are,  therefore,  far  more  amenable  to 
treatment  by  removal,  even  though  they  may  have  attained  a 
large  size.  Mr.  Barker  has  recorded*  a  very  remarkable  case  of 
this  kind,  which  is  depicted  in  Figs.  83  and  84.  The  patient, 
whose  age  was  fifty  when  the  photographs  were  taken,  lived 
no  less  than  eighteen  years  after  the  first  appearance  of  the 
tumour,  and  underwent  in  the  last  ten  years  of  his  life 
numerous  operations  for  the  removal,  first  of<  the  primary 
growth,  and  then  of  locally  recurrent  tumours.     The  tumours 

*  Brit.  Med.  Jour//.,  June  21,  1890,  and  T/n/t.s.  Path.  Sue.  Lond.  18'Ji;.  xlvii 
p.  22.0. 


212  THE   THYROID   GLAND. 

which  were  examined  bv  a  committee  of  the  Pathological 
Society  were  undoubtedly  carcinomatous.  Cases  of  a  similar 
nature  have  been  recorded  by  Berger,  Wiilfler,  Sulzer,  and 
others. 

Treatment. — The  only  form  of  ti-eatment  of  malignant  disease 
of  the  thyroid  that  offers  any  hope  of  cure  consists  in  free 
removal  of  the  whole  of  the  disease,  if  this  is  possible.  Opera- 
tions for  the  removal  of  a  portion  of  a  diseased  thyroid  may 
be  divided  into  two  main  classes,  that  of  extra-capsular  eoctir- 
pat'ion  and  that  of  intra-glandular  emicleation.  In  the  case  of 
malignant  tumours,  however,  one  only  of  these  methods  is 
suitable,  namely,  extirpation.  An  exception  should  perhaps  be 
made  for  certain  cases  in  which  malignant  disease  attacks,  and 
is  limited  to,  an  old  adenoma  with  a  well-marked  fibrous 
capsule  ;  but  as  these  cases  are  rare,  and  can  scarcely  be  distin- 
guished from  those  of  innocent  adenoma,  the  exception  is  rather 
apparent  than  real. 

The  ti-eatment  of  innocent  thyroid  tumours  by  enucleation  is 
such  a  very  satisfactory  operation,  and  is  so  widely  applicable 
to  them,  that  attempts  have  from  time  to  time  been  made  to 
treat  malio-nant  growths  in  the  same  manner.  This  is,  however, 
in  my  opinion,  a  grave  error.  Not  only  is  the  haemorrhage  at 
times  so  profuse  that  the  operation  has  to  be  abandoned  on 
this  account  alone,  but  the  removal  is  almost  necessarily  so 
incomplete,  that  speedy  recurrence  must  be  expected. 

The  only  way  to  remove  a  malignant  thyroid  tumour  satis- 
factorily is  to  do  a  careful  and  deliberate  dissection,  and  to 
avoid  haemorrhage  by  tying  the  main  vessels  before  they  are 
cut.  The  operator  should,  at  every  stage  of  ttie  operation,  be 
able  to  see  exactly  Avhat  he  is  doing.  Otherwise  he  is  liable 
either  unnecessarily  to  w^ound  important  neighbouring  structures 
or  to  leave  behind  portions  of  growth  which  might  well  have 
been  taken  away. 

An  operation  for  the  removal  of  a  malignant  thyroid  tumour 
should,  if  possible,  be  a  thorough  one,  and  aim  at  the  removal 
of  the  whole  of  the  primary  disease.  When  the  disease  is 
limited  to  the  gland  itself,  this  complete  removal  is  possible. 
But,  unfortunately,  in    the   vast    majority  of    cases    in    which 


MALIGNANT   DISEASE   AND    ITS    TREATMENT.      213 

operations  have  hitherto  been  performed,  this  condition  was  not 
present. 

In  most  cases  the  growth  is  found  at  the  time  of  operation  to 
have  penetrated  the  capsule,  and  to  have  involved  the  trachea, 
the  pharynx,  or  the  great  vessels  of  the  neck.  In  such  circum- 
stances it  has  been  thought  advisable  to  resect  portions  of  these 
structures,  but  such  complications  naturally  add  enormously  to 
the  danger  of  the  operation.  In  most  cases  even  after  such 
resections,  the  whole  of  the  disease  will  be  found  not  to  have 
been  removed,  and  speedy  recurrence  takes  place.  The  recur- 
rent tumour  usually  grows  much  more  rapidly  than  the  primary 
one. 

Two  cases  may  here  l)e  cited  : 

In  the  summer  of  1887  I  was  asked  by  Mr.  Howard  Marsh  to  see 
a  man  aged  42  who  had  had  for  five  years  a  hard  lump  in  the  right 
side  of  the  neck.  This  had  steadilj'  increased  in  size,  at  first 
slowly,  in  the  last  few  months  more  rapidly.  A  large,  irregular, 
somewhat  hard  tumour  occupied  most  of  the  anterior  triangle 
of  the  neck  ;'^  the  sympathetic  nerve  of  the  same  side  was  com- 
pletely paralysed.  On  account  of  this  latter  complication  and  of 
the  probable  involvement  of  the  structures  on  the  inner  side  of  the 
tumour,  I  advised  against  any  opei-ation.  However,  a  few  days 
later  the  patient  consulted  another  surgeon  who  proceeded  to 
remove  the  tumour,  and  subsequently  published  an  excellent 
account  of  the  case.f  The  operation  was  long  and  difficult,  and  in 
the  account  given,  it  was  stated  that  the  tumour  was  adherent  to 
the  larynx.  It  was  not  stated  that  the  removal  was  considered  to 
have  been  complete.  The  patient  recovered  sufficiently  to  leave 
the  hospital,  but  in  less  than  sixteen  weeks  from  the  date  of  the 
operation  he  returned  with  a  recurrent  tumour  as  large  as  an 
orange  and  ulcerated  on  the  surface.  The  tumour  was  again  re- 
moved, then  tracheotomy  was  performed.  Several  other  partial 
operations  were  subsequently  performed  ;  sloughing  took  place, 
then  secondary  haemorrhao-e,  necessitatina:  ligature  of  the  carotid. 
The  patient  died  very  soon  after  this  operation,  and  just  nine 
months  from  the  date  of  the  first  removal.  The  growth  was  a 
spindle-celled  sarcoma,  and  at  the  post-mortem  examination  no 
secondary  growths  could  be  discovered. 

*  Fig.  81  sliows  the  condition  at  the  time  when  1  fil■^^t  saw  this  patient. 
■f  8t.  TJiuntai.i!  Husp.  Eev..  18SS-9,  n.  s.  xviii.  p.  233. 


214  THE    THYROID    GLAND. 

The  other  case  is  one  pubHshed  by  Cramer,*  and  also  ilhis- 
trates  incomplete  removal  at  a  rather  later  stage  of  the  disease. 

A  woman  aged  46  had  had  for  two  years  a  small  lump  on  the  left 
side  of  the  neck  ;  in  the  last  nine  months  it  had  grown  more 
rapidly ;  hoarseness  had  then  set  in  and  lately  she  had  had  much 
pain.  On  admission  there  was  no  dyspnoea  or  dysphagia.  The  left 
lobe  of  the  thyroid  was  as  large  as  a  goose's  egg  ;  it  was  smooth, 
Imrd,  and  a  little  movable  ;  the  skin  was  not  affected.  Malig- 
nancy was  diagnosed  and  the  tumour  removed.  Haemorrhage  was 
but  slight,  but  much  difficulty  was  experienced  in  separating  the 
tumour  from  the  trachea  and  larynx.  The  wound  healed  up 
quickly  and  the  paiient  was  on  the  point  of  leaving  the  hospital, 
when  the  wound  suddenly  re-opened  and  some  secondary  haemor- 
rhage took  place.  A  few  days  later  the  wound  was  laid  open 
again  and  the  bleeding  found  to  come  from  a  nodule  of  growth. 
Severe  hseinoptysis  then  took  place.  With  the  laryngoscope  a 
mass  of  growth  jjenetrating  the  trachea  coidd  be  seen.  Seven 
weeks  after  the  original  operation  the  larynx  was  split  open  and 
growth  found  on  the  left  side  extending  from  the  middle  of  the 
thyroid  cartilage  to  the  fifth  tracheal  ring.  A  few  days  later  total 
extirpation  of  the  larynx  was  performed ;  at  first  the  patient 
seemed  to  do  well,  but  in  the  second  week  recurrences  began  to 
be  manifest  at  various  places  in  the  wound,  pleurisy  set  in  and 
eventually  the  patient  died  just  fourteen  weeks  from  the  time 
of  the  first  operation. 

I  cite  these  two  cases,  because  I  believe  them  to  be  fair 
average  examples  of  the  difficulties  that  a  surgeon  must  be 
prepared  to  encounter  if  he  undertakes  the  removal  of  a 
malignant  goitre  when  there  is  no  longer  any  hope  that  the 
growth  is  still  confined  within  the  capsule  of  the  gland. 

The  operation  for  the  removal  of  a  malignant  goitre  in  its 
early  stage,  that  is  before  the  capsule  has  been  penetrated,  should 
be  performed  in  exactly  the  same  manner  as  extracapsular 
extirpation  of  an  innocent  goitre.  An  incision  of  sufficient 
length  is  made,  usually  over  the  long  axis  of  the  tumour,  the 
infrahyoid  muscles  are  divided,  and  the  capsule  of  the  gland 
exposed.     Wound    of   the    capsule  with   its   network    of   large 

*  ••  Beitrag.  z.  Kenntniss  der  Struma  maligna.  "  .lrc7/. /.  /,7///.  Chi/:.  Berlin 
1887.  xxxvi.  p.  2.59. 


MALIGXAXT   DISEASE    AND    ITS    TREATMENT.     215 

vessels  should  be  carefully  avoided.  All  the  main  vessels  enter- 
ing or  leaving  the  gland  are  tied  with  double  ligatures,  just 
outside  the  capsule,  before  being  divided.  After  the  superior 
th>Toid  artery  and  the  superior,  lateral,  and  inferior  thyroid 
veins  have  been  treated  in  this  manner,  the  tumoui"  should,  if 
possible,  be  lifted  up,  and  the  more  deep-seated  inferior  thyroid 
arterv  secured  in  the  same  A\"av.  This  artery  may  be  tied  before 
it  reaches  the  recurrent  larvngeal  nerve,  or  its  branches  may  be 
secured  on  the  inner  side  of  the  nerve,  just  before  they  enter 
the  gland.  Great  care  must  be  taken  to  avoid  wounding  the 
nerve.  The  vessels  at  the  upper  and  lower  borders  of  the 
isthmus  are  secured  with  double  ligatures,  and  the  isthmus  is 
then  divided.  The  whole  lobe  is  then  freed  from  its  remaining 
connections  and  removed.  Ligatures  are  applied  to  any  other 
bleeding  points.  After  the  tumour  has  been  removed  the  cut 
surface  of  the  isthmus  should  be  examined  to  make  sure  that 
the  whole  of  the  growth  has  been  satisfactorily  taken  away.  If 
necessarv,  some  more  of  the  isthmus  may  be  removed.  It  may 
even  be  advisable  to  repeat  the  operation  upon  the  other  half  of 
the  gland.  Total  extirpation  of  the  gland,  however,  is  in  my 
opinion,  rarelv  desirable,  since  if  both  lobes  are  involved  in 
the  disease,  the  growth  has  almost  certainly  already  involved 
the  trachea,  and  can  no  longer  be  satisfactorily  removed. 
The  simultaneous  removal  of  both  halves  of  the  gland  adds 
very  much  to  the  gravity  of  the  operation.  It  should  not, 
I  think,  be  performed  unless  the  operator  feels  confident 
that  he  can  therebv  make  a  complete  removal  of  the  whole 
disease,  and  that  he  cannot  do  this  by  any  smaller  operation. 
It  may  reasonably  be  doubted  whether  the  larger  operations, 
which  include  resection  of  organs  outside  the  gland,  are 
advisable. 

Irrigation  of  the  wound  ^^  ith  antiseptic  solutions  should,  if 
possible,  be  avoided.  Aseptic  rather  than  antiseptic  treatment 
should  be  aimed  at.  It  is  scarcely  necessary  to  add  that  during 
the  whole  operation  the  most  strict  asepsis  should  be  main- 
tained. A  drainage  tube  need  seldom  be  kept  in  the  wound 
for  more  than  twenty-four  hours. 

The  removal  of  one  half  of  the  thyroid  gland,  if  performed  in 
the  manner  indicated,  u]:)on  a  suitable  case,  is  not  more  difficult 


lm6  the  thyroid  gland. 

than  when  performed  for  an  innocent  goitre.  Upon  this  point 
Kocher,  a\  hose  experience  of  both  classes  of  operations  is  very 
large,  says  "  the  prognosis  (as  regards  the  operation)  in  excision 
of  sarcomatous  or  carcinomatous  goitre,  if  performed  at  the 
right  time,  is  not  materially  worse  than  that  of  innocent 
goitre.''^ 

Results  of  Operations  for  the  Removal  of  Malignant  Goitre. 
— In  the  first  edition  of  Butlin's  "  Operative  Surgery  of  Malignant 
Disease "  published  in  1887,  statistical  information  is  given  in 
an  analvsis  of  fiftv  cases  collected  by  Braun  and  Rotter.  Thirty 
of  the  patients  died  from  the  effects  of  the  operation  at  periods 
varying  from  a  few  hours  to  eight  weeks.  Of  the  remaining 
twentv  there  were  two  in  \\'honi  the  operation  was  not  completed. 
In  four  cases  the  further  history  was  not  known  except  for  a 
very  short  period  after  the  operation.  "  In  ten  cases  there  A\as 
recurrence,  which  was  either  fatal  or  promised  rapidly  to  be  so. 
Only  in  four  instances  was  a  favourable  result  obtained."  Two 
of  these  patients  died  of  disease  of  the  lungs  one  year  and  two  and 
a  quarter  years  after  the  operation.  One  patient  was  known  to 
be  alive  and  well  eleven  months  afterwards.  The  remaining 
patient  was  reported  to  be  quite  well  nearly  four  years  after  the 
operation,  but  he  too  is  now  known  to  have  died  of  recurrence 
not  long  after  the  date  of  this  report.  So  that  of  the  whole 
number  there  is  not  one  that  can  be  said  to  have  been  satis- 
factorily cured  by  the  operation. 

Statistical  information  as  regards  the  removal  of  innocent 
goitre  has  within  the  last  few  years  accumulated  rapidly  and 
has  shown  a  marked  improvement  in  this  branch  of  surgery. 
The  gross  mortality  after  partial  extirpation  (not  enucleation) 
of  the  thyroid  for  all  kinds  of  innocent  goitre,  except  the 
exophthalmic  variety,  is  Sh  per  cent.,  according  to  the 
most  recent  statistics  of  Reverdin  (October  1898).  This 
estimate  is  obtained  from  an  analysis  of  1212  cases  reported  to 
him  bv  a  large  number  of  surg-eons. 

Similarly  satisfactorv  improvement  cannot  however  be 
claimed  for  the  removal  of  malignant  thyroid  tumours.  Some 
improvement  has,  however,  taken  place  in  the  direction 
of  earlier  diagnosis  and  a  lessened  mortalitv  from  the  operation 
itself. 


MALIGNANT   DISEASE   AND    ITS   TREATMENT.     217 

Accurate  statistical  information  with  regard  to  the  removal  of 
malignant  thyroid  tumours  is  not  easily  obtained.  Most  of  the 
operators  who  have  published  long  series  of  operations  for 
goitre  have  omitted  from  their  statistics  all  the  malignant 
cases. 

In  a  few  instances,  however,  a  series  of  consecutive  cases  has 
been  published  and  these  afford  us  valuable  information.  Such 
are  the  series  published  by  Sulzer  from  the  Canton  Hospital  at 
Munsterlingen  (seven  cases),  by  Bergeat  from  the  Tiibingen 
Clinic  (six  cases),  by  Hochgesand  from  the  Heidelberg  Clinic 
(five  cases),  and  the  latest  series,  published  by  Kocher  and  his 
assistants,  from  the  Berne  Clinic  (eighteen  cases).  Besides  these 
I  have  collected  from  various  sources  thirteen  isolated  cases 
published  by  various  authors,*  since  1887.  With  the  possible 
exception  of  some  of  the  operations  mentioned  by  Sulzer,  the 
exact  dates  of  many  of  which  I  do  not  know,  all  these  operations 
have  been  performed  since  1884.  Many  of  them,  including  all 
of  Kocher's  series,  are  quite  recent,  having  been  performed 
withirj  the  last  few  years.  Five  of  Hochgesand's  cases  I  have 
excluded  from  my  statistics  because  they  were  performed  before 
1884  and  have  already  been  included  in  Braun's  statistics  above 
mentioned.  I  have  also  excluded  cases  of  papilliferous  cyst,  on 
account  of  its  low  degree  of  malignancy.  The  thirteen  isolated 
cases  include  only  those  in  which  there  was  clear  microscopical 
or  other  proof  of  malignancy. 

Of  the  total  number  of  fortv-nine  cases,  there  were  seventeen 
in  which  death  occurred  as  the  result  of  the  operation  itself. 
This  gives  us  a  mortality  of  thirtv-four  per  cent.,  a  distinct 
improvement  upon  the  sixty  per  cent,  of  the  earlier  series. 
Kocher's  figures  alone,  which  show  six  deaths  among  eighteen 
patients,  indicate  a  great  improvement  upon  the  results  of  his 
earlier  operations.  They  may  be  taken  as  representing  the  best 
results  that  can  be  obtained  at  the  present  day  when  the  opera- 
tion is  undertaken  by  a  surgeon  who  is  especially  experienced  in 
this  branch  of  surgery  and  who  does  not  refuse  to  operate  upon 
tumours  that  have  already  gone  beyond  the  limits  of  the  gland 
itself.     It  is  the  presence  of  severe  complications  that  makes  the 

*  Cramer.  Frank.  Petrakides.  Buschi.  Berry.  Jones  and  Battle,  Lentz,  Allen 
Davis.  Stonliani.  Ewald.  Orcel.  and  Kuuuner. 


218  THE   THYROID    (iLAXD. 

operation  so  fatal  in  itself  and  which  causes  its  mortality  to  be 
so  very  much  greater  than  that  of  operations  for  innocent  goitre. 
Kocher's  own  remarks  upon  this  subject  are  well  worth  quoting. 
Speaking  in  1898  of  the  relatively  high  mortality  in  his  series  of 
eighteen  cases,  he  says  : 

"It  is  not  the  goitre  operation  in  itself  which  leads  to  the  fatal 
result,  but  the  severe  complications  which  the  resection  of  neigh- 
bouring structures  brings  with  it.  In  most  cases  it  is  necessary  in 
removing  a  malignant  goitre  to  excise  at  the  same  time  portions  of 
the  trachea  or  oesophagus,  or  even  the  whole  of  these  structures  as 
far  as  they  lie  in  the  neck.  Quite  common  in  these  operations  are 
resections  of  the  great  vessels  of  the  neck,  most  often  the  internal 
jugular  vein,  occasionally  also  the  carotid.  Important  nerves  too, 
such  as  the  vagus  and  sympathetic,  must  in  many  cases  be  wounded 
or  resected.  When  these  severe  complications  are  taken  into 
account,  the  healing  of  the  wound  in  two-thirds  of  all  cases  of 
malignant  goitre  may  be  considered  to  be  a  comparatively  favourable 
result,  since  the  end  of  such  patients,  if  the}'  do  not  undergo  any 
operation,  is  usually  preceded  by  great  suffering  and  distress, 
either  from  dysphagia  or  extreme  dyspnoea.  It  is  to  be  wished 
that  every  doctor  could  be  brought  face  to  face  with  such  patients 
in  the  later  stages  of  their  malady,  so  that  he  might  thoroughly 
appreciate  the  necessity  of  an  early  diagnosis  and  timely  operative 
interference.  .  .  .  Every  goitre  in  an  adult,  and  especially  in  an 
elderly  person,  that  enlarges  without  obvious  cause,  should  raise  a 
suspicion  of  malignancv,  even  though  it  cause  no  pain  or  other 
trouble  ;  and  if  at  the  same  time  the  goitre  becomes  harder  and 
irregular,  and  symptoms  of  increasing  distress  set  in,  then  the 
diagnosis  becomes  almost  certain." 

AA'e  may  turn  now  to  the  ultimate  results  of  the  operation. 
From  the  thirty-two  patients  that  recovered  from  the  operation 
we  must  unfortunately  deduct  twelve  cases  of  Kocher's,  since 
Avith  regard  to  them  no  information  has  yet.  so  far  as  I  can 
learn,  been  published.  We  must  also  deduct  six  other  cases  of 
which  there  was  no  history  for  more  than,  at  most,  four 
months. 

^Xe  are  left  therefore  with  the  comparatively  small  number  of 
fourteen  cases ;  of  these  no  less  than  eleven  either  died  within  a 
year  or  were  known  to  have  recurrence.  Three  only  were 
known  to  have  survived  and  to  be  free  from  recurrence  for  a 


MALIGNANT   DISEASE    AND    ITS   TREATMENT.     219 

period  of  three  years  and  two  months,  two  years  and  seven 
months  and  eight  months  respectively — truly,  not  a  very 
encourao-inor  list. 

The  three  cases  were  : 

(1)  A  man  from  whom  in  May  1889  the  left  lobe  of  the  thyroid 
was  extirpated  on  account  of  round-celled  sarcoma.  When 
examined  in  July  1892^  this  patient  showed  no  signs  whatever 
of  recurrence  and  appeai-ed  to  be  in  fairly  good  health,  although 
suffering  to  some  extent  from  thyroidal  atrophy,  symptom^s  of 
which  had  indeed  been  present  before  the  operation.     (Sulzer.) 

(2)  A  boy  aged  10  in  whom  a  "  hyperplastic  "  goitre  was  supposed 
to  have  become  sarcomatous  ;  there  was  slight  dyspnoea.  In  July 
1885,  the  tumour,  which  contained  numerous  cysts  with  hfemor- 
rhagic  contents  (surely  an  unusual  form  of  malignant  disease  !),  was 
removed  by  what  seems  to  have  been  an  atypical  enucleation 
operation.  In  February  1888,  there  was  no  recurrence  and  he 
seems  to  have. been  quite  well.     (Hochgesand.) 

(3)  A  woman  aged  54  with  a  left-sided  "  malignant "  goitre 
as  large  as  a  fist.  There  was  much  dyspnoea  and  dysphagia.  In 
June  1887  the  tumour  was  extii-pated,  the  oesophagus  being  opened 
in  the  course  of  the  operation.  Five  weeks  later  oesophago- 
tomy  was  successfully  performed  for  the  closure  of  the  fistulous 
opening  that  was  present.  The  patient  made  a  good  recovery, 
and  in  February  1888  was  reported  to  be  in  good  health.  (Hoch- 
gesand.) 

In  neither  of  the  two  last  cases  is  it  stated  that  any  micro- 
scopical examination  of  the  tumour  was  made. 

The  results  of  the  operations  in  the  two  series  of  cases, 
those  collected  by  Rotter  and  by  myself,  are  shown  in  the 
following-  tabular  form.  The  two  cases  in  which  the  opera- 
tion was  not  completed  have  been  omitted  from  Rotter's  series 
of  fifty  cases,  and  the  whole  of  Kocher's  cases  from  the  second 
series. 


^20  THE   THYROID    GLAND. 

Earlit'i-  si-rics  bt'l'on'  l.SSi).      Later  series. 

Died  of  the  operation  ...  ...     iiO  {(Y2  p.c.)  ll(35p.c.) 

Further  history  unknown     ...  ...        4  6 

Known  to  have  had  recurrence  or  to 

have  died  within  a  year  ...      1 0  11 

Known  to  have  survived  without  re- 
currence for  periods  varying 
from  eight  months  to  two  years 
and  a  half  ...  ...  ...        3  2 

Known  to  have  sux'vived  without  re- 
recurrence  for  more  than  three 
years  ...  ...  ...        1  1 

Totals  48  31 

The  statistics  given  above  show  clearly  that  in  the  vast  majority 
of  eases  the  operation  as  usually  performed  does  not  result  in  a 
cure.  It  is  much  to  be  regretted  that  we  have  at  present  no 
reliable  statistical  information  as  to  the  results  of  operations 
undertaken  in  the  early  stages  only,  that  is  before  the  penetra- 
tion of  the  capsule  has  occurred. 

These  are  the  cases  in  which  we  might  reasonably  hope  that 
the  operation  Avould  be  of  much  benefit  to  the  patient. 

Cases  in  which  a  long  period  of  immunity  has  followed  an 
operation  undertaken  at  this  early  stage  are  occasionally  seen. 

In  the  Philadelphia  Annals  of  Surgery  (1893,  p.  554)  is  an 
account  of  a  discussion  which  took  place  at  the  New  York 
Surgical  Society  in  May  of  that  year  on  a  case  of  malignant 
goitre.  Dr.  F.  Kanmierer  was  reported  to  have  then  said  that 
"  of  several  total  extirpations  for  malignant  disease  he  recalled 
two  in  which  the  growth  had  not  perforated  the  capsule.  One 
Avas  a  very  large  cancerous  thyroid  and  there  was  no  recurrence 
after  extirpation  for  four  years,  when  recurrence  did  take  place, 
and  it  ran  a  rapid  and  fatal  course.  In  another  case  in  which 
the  diagnosis  was  established  without  doubt,  the  patient  is  still 
living  without  any  recurrence  seven  or  eight  years  after  total 
extirpation." 

These  remarks,  if  confirmed,  seemed  to  me  to  be  of  such 
importance  that  I  wrote  to  Dr.  Kammerer  asking  for  further 
information  with  which  he  very  kindly  supplied  me.  It 
appeared,  then,  that  the  fir.st  case  was  one  of  Maas's,  already  men- 


MALIGNANT   DISEASE    AND    ITS    TREATMENT.     221 

tinned  among  Rotter's  cases.  It  is  sad  to  think  that  the  best 
case  of  all  in  this  series  should  eventually  have  died  of  recurrence. 
It  is  some  satisfaction,  however,  to  know  that  a  patient  can  live 
without  recurrence  for  as  much  as  four  years  after  the  removal 
of  a  goitre,  the  malignant  nature  of  which  is  established  without 
doubt. 

The  other  case  that  Kammerer  had  seen  is  still  more  impor- 
tant, as  it  shows  that  a  patient  may  survive  the  operation  for  a 
period  of  not  less  than  eleven  years.  It  is  that  of  a  gentleman 
operated  on  by  Kocher  in  or  before  the  year  1885.  The  exact 
date  of  the  operation  I  have  unfortunately  not  succeeded  in 
obtaining,  but  it  appears  to  be  quite  certain  that  it  was  not  later 
than  1885,  and  was  probably  somewhat  earlier.  In  1893  this 
patient  was  operated  upon  for  the  first  recurrence  by  Dr.  Lange 
of  New  York,  under  whose  care  he  remained  during  the  next 
three  years.  Tracheotomy  was  eventually  performed  and  a  long 
canula  inserted.  Extensive  recurrences  took  place  and  the 
patient  died  in  August  1896,  having  survived  the  first  operation 
for  a  period  of  at  least  eleven  years.  Dr.  Kammerer  tells  me 
that  Kocher  had  stated  that  the  tumour  removed  at  the  first 
operation  was  malignant.  With  regard  to  the  nature  of  the 
recurrent  tumour  I  have  a  report  from  Dr.  Schwyzer,  pathologist 
to  the  German  Hospital,  New  York,  who  made  the  post-mortem 
examination,  and  who  states  that  the  tumour  was  a  "  tubular 
carcinoma  with  much  interstitial  connective  tissue." 

The  tumours  known  under  the  names  of  papuliferous  cyst  and 
papilliferous  cystic  adenoma  form  a  class  of  malignant  tumours 
that  stand  somewhat  apart  from  the  ordinary  carcinoma  and 
sarcoma.  They  are  much  less  malignant.  They  grow  slowly  and 
exhibit  much  less  tendency  either  to  infiltrate  locally  or  to  dis- 
seminate. In  these  respects  they  are  analogous  to  the  papilliferous 
cystoma  of  the  ovary,  which  they  closely  resemble.  The  patients 
are  much  less  liable  to  speedy  recurrence  after  operation.  In 
Barker's  case,  already  mentioned,  the  tumour  had  been  growing 
for  eight  years  before  the  first  operation  was  performed.  Death 
did  not  occur  till  ten  years  later  still.  Berger  records  the  case 
of  a  woman  aged  twenty-six  in  whom  a  large  tumour  of  this 
nature  had  been  growins;  for  six  vears.  It  was  then  removed 
with  some  difficulty  owing  to  its  intimate  adhesions  with  the 


222  THE   THYROID   (ILAND. 

internal  jugular  vein  ;  eight  months  later  this  patient  was  well 
and  had  had  no  recurrence,  Wolfler  cites  from  Billroth's 
practice  the  case  of  a  woman  aged  twenty-three  in  whom  the 
tumour  at  the  time  of  operation  occupied  a  large  part  of  the 
neck.  It  had  been  growing  for  one  year.  Two  years  after  the 
operation  no  recurrence  had  taken  place. 

Palliative  Treatment. — Although  radical  and  curative  treat- 
ment of  malignant  disease  of  the  thyroid  is  in  most  cases  im- 
]iracticable,  yet  something  can  be  done  for  these  unfortunate 
patients  bv  palliative  treatment. 

A  partial  removal  of  the  disease  will  occasionally  afford  relief 
for  a  time,  especially  from  the  dyspnoea.  As  the  operation  is 
intended  only  to  relieve  symptoms,  it  should  not  be  done  until 
these  symptoms  are  already  sufficiently  severe  to  cause  consider- 
able distress.  Partial  and  incomplete  removal  of  the  disease 
does  nothing  to  check  the  progress  of  the  disease  itself  and,  if 
undertaken  too  soon,  may  easily  make  the  patient  worse  than 
before.  It  should  seldom  be  performed  unless  there  is  a  reason- 
able prospect  that  the  external  wound  will  heal.  It  is  chiefly 
useful  when  a  mass  of  growth  is  pressing  injuriously  upon  the 
trachea.  Any  incision  into  the  growth  is  apt  to  lead  to  funga- 
tion  into  the  wound,  and  if  the  latter  become  septic,  a  contin- 
gency often  difficult  to  avoid,  the  operation  may  do  more  harm 
than  good. 

The  following  case  is  one  in  which  a  partial  extirpation 
aflTorded  considerable  temporary  relief. 

Mrs.   Fanny  M ,  wf.   50,  was  admitted  into  the  Royal  Free 

Hospital  under  mj^  care  on  July  7,  1900,  suffering  ft-om  dyspnoea, 
dysphagia,  and  a  tumour  of  the  thyroid  gland. 

In  September  1899  she  had  first  noticed  a  swelling  of  the  neck. 
This  gi'adually  increased  in  size  and  caused  her  a  good  deal  of  jjain 
in  the  shoulder  and  neck.  In  February  1900  she  was  admitted  to 
King's  College  Hospital,  and  on  March  1  underwent  there  an 
operation  for  the  removal  of  the  tumour.  At  this  time  the  tumour 
was  hard  and  irregular  and  involved  both  lobes  of  the  gland.  It 
moved  with  the  larynx  on  deglutition.  The  growth  was  found  to 
be  a  sarcoma.  The  wound  healed  quickly,  the  patient  soon  left 
the  hospital  and  was  much  relieved  by  the  operation.  A  week 
or   two    later    recurrence    was  noticed  in    the    neighbourhood    of 


MALIGNANT   DISEASE   AND   ITS   TREATMENT.     223 

the  scar.  For  three  months,  however,  she  remained  fairly  well. 
Towards  the  middle  of  June  dyspnoea  and  dysphagia  again  became 
yery  troublesome,  and  for  these  symptoms  she  came  under  my  care. 
At  this  time  the  thyroid  gland  was  found  to  be  much  enlarged, 
each  lobe  being  as  large  as  a  goose's  egg.  It  was  yery  hard  and 
much  fixed.  The  tumour  was  yery  deeply  seated,  lying  largely 
behind  the  sternum.  There  was  great  dyspnoea  with  much  stridor, 
and  the  patient  was  in  great  distress.  The  vocal  cords  however 
were  still  unaffected.  On  July  li,  a  palliative  operation  was 
undertaken  with  the  view  of  removing  that  portion  of  the  tumour  ' 
that  lay  behind  the  sternum,  and  that  was  evidently  pressino- 
seriously  upon  the  trachea.  No  hope  was  held  out  of  performing  a 
complete  removal  of  the  disease.  A  mass  of  growth  as  large  as  an 
apple  and  weighing  four  ounces  was  removed  from  the  root  of  the 
neck  and  superior  mediastinum.  The  operation  presented  no 
special  difficulty  and  bleeding  was  not  excessive.  The  trachea 
was  found  to  be  greatly  compressed  but  not  actually  infiltrated. 
The  growth  on  the  left  side  was  extensively  adherent  to  the 
internal  jugular  vein,  pharynx  and  CESophagus,  and  no  attempt  was 
made  to  remove  this  portion  of  it.  As  before,  the  wound  healed 
by  first  intention,  and  on  July  25,  the  patient  returned  to  her 
home  in  the  country,  breathing  freely  and  much  relieved.  In 
September  the  patient  came  up  to  see  me  again.  She  was 
breathing  comfortably  and  her  general  condition  was  fairly  good. 
She  could  swallow  liquids  without  trouble,  but  not  solids.  Two 
months  later  however  very  severe  attacks  of  dyspnoea  occurred  and 
she  was  re-admitted  much  exhausted  from  dyspnoea,  pain  and 
recurrence  of  growth.  Tracheotomy  Avas  performed  in  November, 
a  Koenig's  canula  being  inserted.  This  gave  her  temporary  relief. 
On  November  12,  1900  she  died  rather  suddenly,  apparently  from 
exhaustion  from  the  disease  and  without  having  had  any  retlirn  of 
dyspnoea. 

The  post-mortem  examination  showed  very  extensive  disease  of 
both  lobes.  The  groAvth  extended  downwards  to  the  first  ribs  and 
apices  of  the  lungs.  Behind  the  trachea  it  formed  a  firm  dense  plate 
more  than  an  inch  thick,  completely  surrounding  the  oesophagus. 
(^See  Fig.  78,  p.  203,  and  case  113,  p.  352.)  There  were  no  secondary 
growths.    Microscopical  examination  shoAved  spindle-celled  sarcoma. 

A  simple  incision  doAvn  to  or  into  a  goitre  that  is  the  seat  of 
irremovable  malignant  disease  Avill  occasionally  relieve  the 
dyspnoea.  This  is  effected  doubtless  by  causing  shrinking  of 
the  non-malignant  portions  of  the  goitre.     This  operation  has 


224.  THE    THYROID    GLAND. 

been  practised  for  malignant  disease  more  often  in  France  than 
elsewhere.*  Mr.  Geortje  Turner  has  recorded  an  interestino- 
case  in  which  he  had  to  perform  tracheotomy  for  a  malignant 
goitre.  The  operation  caused  almost  complete  disappearance 
of  all  swelling  in  the  neck.  So  remarkable  was  this  disappear- 
ance that  the  correctness  of  the  diagnosis  was  questioned.  But 
a  subsequent  recurrence  of  the  growth  placed  its  malignant 
nature  beyond  dispute. f 

Tracheotomy  often  affords  the  only  means  open  to  us  of 
alleviating  the  dyspnoea  from  which  these  unfortunate  patients 
suffer.  As  a  rule  it  should  be  performed  only  when  the  dyspnoea 
has  become  a  source  of  considerable  distress  to  the  patient. 
Occasionally  it  may  be  performed  early,  if  there  are  any  indica- 
tions that  (edema  of  the  glottis  is  likely  to  supervene.  It 
should  be  remembered  that  this  complication  may  occur  without 
much  warning  and  may  rapidly  prove  fatal  if  not  relieved  by  a 
timely  tracheotomy. 

The  difficulties  of  a  tracheotomy  may  be  considerable.  If 
the  growth  is  not  large  and  does  not  displace  or  cover  up  the 
trachea,  then  the  operation  is  generally  easy  to  perform.  The 
close  proximity  of  the  growth  however  is  apt  to  cause  enlarge- 
ments of  the  veins  of  the  neck  and  this  may  render  the  operation 
difficult.  The  trachea  may  be  so  much  displaced  that  the 
incision  has  to  be  made  far  away  from  the  middle  line.  Thus 
in  the  case  depicted  in  Fig.  77  I  had  to  make  the  skin  incision 
nearly  an  inch  and  a  half  to  the  right  of  the  middle  line.  In 
another  case  in  which,  some  years  ago,  I  helped  my  friend  Mr. 
Stanley  Boyd  at  a  tracheotomy  for  a  sarcoma  of  the  thyroid, 
the  incision  had  to  be  made  equally  far  out  on  the  left  side  of 
the  neck. 

It  should  be  borne  in  mind  that  when  the  trachea  is  much 
displaced  its  relation  to  the  carotid  becomes  seriously  altered. 
In  both  these  cases  the  trachea  had  been  pushed  outwards  under 
the  carotid  artery.  The  tracheotomy  was  done  just  below  the 
cricoid.  Had  it  been  done  lower  down  the  carotid  would  have 
been  encountered,  since  it  was  found,  when  the  patients  eventually 

*  See  Adeiiot.  "  Liberation  longitudinale  de  la  traciiee  coiiime  traiteuieiit 
palliatif  dans  le  cancer  du  corps  thyroide,"  Axsoe.  franc,  de  Cli'ir.,  Paris,  1896, 
X.  p.  320.  -j-  Trun:-.  CJln.  S;u-.,  London.  1890.  xxiii.  p.  226. 


MALIGNANT   DISEASE   AND    ITS   TREATMENT.     22^ 


died,  that  it  Jay  directly  in  front  of  the  trachea,  more  than  an 
inch  above  the  sternum. 

Frequently  the  tracheotomy  has  to  be  done  directly  through 
the  growth  if  the  latter  covers  the  front  of  the  trachea  ;  or,  as 
in  a  recent  case  of  my  own,  it  may  be  necessary  to  remove  some 
portion    of  the   growth         ,    ""~^^\ 


in  order  to  reach  the    / 

trachea.     Sometimes  the  f  '  \ 

tracheotomy  can  be  done   V^ 

above  the  growth,  rarely 

is  it  possible  to  do  it  below  the  tumour. 

The  difficulty  of  finding  the  trachea, 
imbedded  as  it  may  be  in  a  mass  of  hard 
growth  and  much  distorted  and  flattened, 
is  often  very  great.  An  ordinary  trache- 
otomy tube  is  frequently  not  long  enough 
to  reach  the  trachea  or  to  pass  beyond 
the  lowest  point  of  constriction.  The 
long  flexible  silver  tube  of  Koenig  I  have 
found  useful  in  such  cases  (see  Fig.  85). 
If  this  is  not  at  hand  a  flexible  catheter 
may  be  used  as  a  substitute. 

Tracheotomy  does  not  usually  prolong 
the  patient's  life  for  more  than  a  few 
weeks  at  most,  but  it  may  add  consider- 
ably to  his  comfort.  If  the  growth  has 
been  incised,  as  it  probably  has  been  in 
the  performance  of  the  operation,  then 
septic  changes  are  apt  to  occur  sooner  or 
later  in   the  tumour.     Bronchitis,  pneu- 

.,  .  .  1  ill       Fig.  8 5. — Koenig's  long- flexible 

monia  or  other  septic  pulmonary  troubles     tracheotomy  tube,  for  tra- 
are  frequently  the  immediatecause  of  death,     ciieotomy  in  cases  of  maiig- 

In  the  case  of  some  slow -growing  malig- 
nant tumours  the  duration  of  life  after  the 
tracheotomy  may  be  much  longer,  especially  if  it  has  been 
possible  to  avoid  cutting  into  the  growth  itself.  Sir  Felix  Semon 
has  recorded  a  very  remarkable  case  of  a  lady  aged  52,  upon  whom 
he  performed  a  low  tracheotomy  a  few  weeks  after  the  first  symp- 
toms of  the  disease  had  been  .noticed.    She  survived  the  operation 


uant     and     other     tuinoiu-s 
pressing-  upon  the  trachea. 


226  THE   THYROID    GLAND. 

more  than  two  years.  In  this  case,  however,  the  amount  of  dysp- 
noea at  the  time  of  operation  does  not  seem  to  have  been  very 
^reat.  The  case  was  in  other  respects,  too,  a  very  unusual  one.* 
If  dysphagia  be  a  marked  symptom,  as  it  often  is,  special 
means  may  have  to  be  taken  to  feed  the  patient.  This  is  best 
effected  by  means  of  an  (esophageal  tube.  Gastrostomy  even 
has  been  performed  in  such  a  case. 

Finally,  morphia  and  other  sedatives  may  have  to  be  ad- 
ministered freely  in  the  later  stages  of  this  most  distressing  and 
painful  disease. 

Conclusions. — Theoperation  for  removal  of  the  ordinary  forms 
of  malignant  disease  of  the  thyroid  gland,  unless  performed  at  a 
very  early  stage  of  the  disease,  is  attended  by  a  high  mortality 
from  the  operation  itself. 

The  danger  lies  chiefly  in  the  involvement  of  important 
neighbouring  structures,  portions  of  which  must  often  be  cut 
away  if  the  primary  disease  is  to  be  thoroughly  removed. 

The  diagnosis  of  the  earlier  stages  of  the  disease  is  not  easy 
and  it  is  especially  difficult  to  say  with  certainty  that  the  trachea 
and  pharynx  are  not  already  involved. 

If  the  disease  has  not  already  penetrated  the  glandular 
capsule,  the  operation  is  not  particularly  difficult  or  dangerous, 
if  the  dissection  is  performed  carefully  and  with  due  regard  to 
the  anatomical  relations  of  the  parts. 

Recurrence  after  operation  is  usually  local  and  due  to  in- 
complete removal  of  the  primary  disease. 

In  the  later  stages  of  the  disease  secondary  deposits  are  likely 
to  be  found  in  the  lungs  and  bones. 

There  are  certain  forms  of  slow  growing  malignant  disease 
such  as  the  papilliferous  cyst,  in  which  the  tendency  to  local 
and  general  malignancy  is  but  slight  and  in  which  treatment  by 
operation  affords  satisfactory  results,  even  when  the  tumour  has 
attained  a  very  large  size. 

In  the  majority  of  cases  of  malignant  disease  of  the  thyroid, 
the  only  treatment  that  can  be  adopted  is  but  palliative,  and 
consists  chiefly  in  relieving  the  patient  from  dyspnoea,  dysphagia 
and  pain. 

*  "  A  Case  of  Malignant  Disease  of  the  Thyroid  Gland  with  ino-st  unusual 
course,''  Med.  Chir.  Trails..  1892-3,  Ixxvi.  p.  375. 


CHAPTER   XIV. 

TREATMENT  OF  INNOCENT  GOITRE— NON-OPERATIVE. 

General — Eemoval  of  cause — Medicinal — Iodine — Thyi-oid  extract 
— Other  di-ugs — Cases  suitable  for — Local — External  applications — • 
Indian  method. 

The  non-operative  measures  that  may  be  adopted  for  the 
treatment  of  innocent  goitre  mav  be  classified  as  follows  : — 
(1)  General;    (2)  Medicinal;    (3)  Local. 

(1)  General. — It  is  obvious  that  if  the  cause  of  goitre  be 
known,  the  patient  should,  as  far  as  possible,  be  removed  from 
its  influence.  This  is  especially  important  in  the  early  stages  of 
the  parenchymatous  form.  Tumours  of  the  gland,  such  as  cysts 
or  adenomata,  although  they  may  have  originated  in  a  gland 
that  was  the  seat  of  parenchvmatous  enlargement,  are  not  likely 
to  be  influenced  in  their  course  by  the  removal  of  the  original 
cause.  Goitres  in  which  other  secondary  changes,  such  as 
fibrosis  and  calcification,  have  occm-red,  are  naturally  not  amen- 
able to  any  such  treatment. 

But  in  the  case  of  early  parenchvmatous  goitres,  care  should 
be  taken  to  remove,  if  possible,  the  cause  of  the  disease.  If  the 
patient  be  living  in  a  district  where  goitre  abounds,  it  is  well 
that  he  should,  if  possible,  remove  to  a  district  where  the  disease 
is  not  prevalent.*  When  such  removal  is  not  convenient  or 
possible,  as  is  generally  the  case,  then  particular  attention  should 
be  paid  to  the  drinking-water,  since  this  is,  in  the  great  majority 
of  cases,  the  cause  of  the  affection.  So  long  as  we  are  ignorant 
of  the  exact  nature  of  the  poison  that  produces  goitre,  it  is 
difficult   to   sav  definitely  how  the    drinking-water   should    be 

*  I  have  known  several  instances  in  which  young  girls  had  been  sent  to 
school  in  a  goitrous  district  and  had  there  developed  the  disease.  Upon  leaving 
the  district  the  goitre  disappeared  spontaneously. 


228  THE    THYROID    GLAND. 

treated,  in  order  to  render  it  innocuous  from  this  point  of  view. 
It  is  well  in  most  instances,  however,  to  recommend  that  water 
suspected  of  being  the  cause  of  goitre  should  not  be  drunk 
without  previous  filtration  and  boiling.* 

As  a  general  rule  it  may  be  stated  that  the  younger  the 
patient  and  the  smaller  the  goitre,  the  more  likely  is  a  cure  to 
be  affected  bv  such  measures  as  removal  from  the  affected 
district  or  bv  alteration  of  the  drinking-water. 

{H)  Medicinal. — Numerous  medicinal  remedies  have  been 
employed  for  the  treatment  of  goitre.  By  far  the  most  im- 
portant are  iodine  and  its  various  preparations,  and  thyroid 
extract,  thvroidin,  and  the  other  preparations  of  the  thyroid 
gland  itself.  For  parenchymatous  goitre  I  usually  recommend 
about  five  minims  of  the  tincture  of  iodine  together  with  four 
or  five  grains  of  iodide  of  potassium,  the  doses  being  gradually 
increased  until  the  patient  is  taking  three  or  four  times  as  much. 
For  the  iodine  treatment  to  be  efficacious,  it  is  desirable  that  the 
drug  be  administered  in  sufficiently  large  doses.  Care  should 
be  taken,  however,  to  diminish  or  stop  the  administration  if 
svmptoms  of  iodism  are  produced  or  if  the  digestion  be  upset. 
If  iodine  in  full  doses  does  not  produce  a  marked  diminution  in 
the  size  of  the  goitre  in  the  course  of  two  or  three  weeks,  it  is 
not  likely  that  it  will  be  of  much  use. 

The  preparations  of  thyroid  gland  are  also  extremely  useful 
in  the  treatment  of  parenchymatous  goitre.  I  have  sometimes 
found  thvroid  extract  useful  in  cases  that  have  not  yielded  to 
iodine  and  vice  verm.  As  thyroid  extract  is  a  potent  and  sometimes 
even  dangerous  drug,  it  is  Avell  to  be  cautious  in  its  adminis- 
tration and  to  begin  with  small  doses. 

Arsenic,  mercurv,  strychnia,  and  various  other  drugs  have  been 
recommended,  and  have  sometimes  appeared  to  me  to  be  of  use. 
Medicinal  treatment  is  most  efficacious  in  the  case  of  general 
enlargement  of  the  gland,  that  is,  of  parenchymatous  goitre. 
Upon  encapsuled  adenomata  it  has  little  or  no  influence,  and  for 
cysts  it  is  equally  useless.  Many  cases,  however,  of  parenchy- 
matous goitre  do  not  yield  at  all  to  medicinal  treatment. 

The  following  case  may  be  cited  as  an  illustration  of  the  use 
of  iodine  and  thyroid  extract  in  parenchymatous  goitre : — 
*  See  Liistig  and  Carle's  expennieiits,  pp.  68.  69. 


TREATMENT   OF    INNOCENT    GOITRE.  529 

Alfred  A ,  cet.  l~ ,  came  under  my  care  at   St.  Bartholomew's 

Hospital  in  January  IPOO^,  on  account  of  dyspnoea  and  enlargement 
of  the  thyroid  gland.  The  thyroid  swelling  had  been  first  noticed 
eighteen  months  previously  and  had  been  gradually  increasing  in 
size.  It  had  caused  difficulty  in  breathing,  especially  at  night  and 
on  exertion. 

The  patient  was  a  deaf  mute,  somewhat  mentally  deficient,  but 
not  showing  any  signs  of  cretinism.  He  was  found  to  have  a  large 
bilateral,  nearly  symmetrical,  goitre.  Each  lateral  lobe  was  as  big 
as  a  goose's  &g,g  ;  the  right  was  slightly  larger  than  the'  left.  The 
gland  was  moderately  firm^  slightly  nodular,  and  mo\ed  freely  with 
the  larj-nx.      There  was  a  moderate  amount  of  tracheal  stridor. 

The  diagnosis  was  parenchymatous  goitre,  with  perhaps  a  few 
adenomata  deeply  buried  in  it. 

Tr.  lodi  Vi\\.  and  Pot.  lod.  gr.iv.  were  given  three  times  a  day 
with  a  tabloid  of  thyroid  extract  (gr.i^)  every  other  day.  The  dose 
of  each  drug  was  increased  every  week.  This  treatment  was  begun 
earh'  in  January.  By  the  end  of  the  month  the  goitre  had 
diminished  to  half  its  original  size  and  was  much  softer.  All 
dyspnoea  had  disappeared.  The  administi*ation  of  thyroid  extract 
was  noAv  discontinued  and  the  doses  of  the  other  drugs  increased 
to  111^ xii.  of  Tr.  lodi  and  gr.xi.  of  Potassium  Iodide.  By  the  end 
of  February  the  general  swelling  of  the  gland  had  almost  dis- 
appeared, but  at  the  lower  part  of  the  right  lobe  a  rounded  firm 
tumour  as  large  as  a  marble  could  be  felt  vei'y  easily.  This  was 
evidently  a  cyst  or  an  adenoma.  As  it  caused  no  trouble  no  further 
treatment  seemed  necessary. 

(3)  Local. — A  common  and  often  useful  method  of  treating 
parenchymatous  goitre  consists  in  painting  the  neck  with  tinc- 
ture or  liniment  of  iodine,  or  in  rubbing  the  swelling  with 
ointments  of  iodine  or  mercurv. 

It  is  possible  that  the  mechanical  pressure  mav  also  do  some 
good  bv  favouring  the  absorption  of  the  accumulated  colloid. 
\  iolent  rubbing  should,  however,  be  avoided,  as  it  is  apt  to 
damao-e  the  softened  o-land  and  to  lead  to  extravasation  of  blood 
within  its  substance. 

I  have  occasionally  endeavoured  to  diminish  the  size  of  a  soft 
parenchymatous  goitre  bv  continuous  gentle  pressure  applied  by 
means  of  a  broad  elastic  band,  but  without  very  satisfactory 
results. 

The  Indian  method  consists  in  smearing  the  goitre  thickly 


230  THE   THYROID    GLAND. 

with  biniodide  of  nieicurv  oiiituicnt  and  then  exposing  the 
})atient's  neck  to  the  rays  of  a  hot  sun.  The  treatment  is  said  to 
be  very  successful  in  India,  but  in  this  country,  where  the  rays  of 
the  sun  are  less  powerful,  the  beneficial  effects  are  not  so  marked. 
I  have  been  informed  by  surgeons  who  have  employed  this 
method  in  India  that  the  patients  are  exposed  to  the  sun  for  an 
hour  or  more,  and  that  the  ointment  has  to  be  well  rubbed  into 
the  neck.  The  result  is  that  the  neck  is  terribly  blistered,  but 
the  goitre* is  frequently  cured. 

I  have  tried  to  imitate  this  Indian  process  by  making  the 
patient  sit  for  an  hour  or  more  at  a  time  with  the  face  covered 
and  the  neck  exposed  before  a  very  hot  fire.  But  I  cannot  say 
that  I  have  met  with  much  success. 


CHAPTER   XV. 

TREATMENT   BY    TAPPING— INJECTION— INCISION— 

SETON— LIGATURE    OF   THYROID  ARTERIES— 

EXOTHYROPEXY. 

Tapping :  For  cystic  goitre — Occasionally  cures — Risks  of — HcBinor- 
rlaage.  Injection :  Of  parenchymatous  goitre — Directions — Risks — 
Fatal  cases — Of  cystic  goitre — Directions — Risks — Results.  Incision  : 
Rarely  desirable — Cases  suitable  for.  Seton :  Dangers  of.  Liga- 
ture of  thyroid  arteries  ;  Historical — Recent  revival — Methods 
of  operating.  Exothyropexy  :  Historical — Objects  of — Objections 
— Methods  of  operating — Results — Complications — Mortality. 

Tapping. — Like  most  other  cystic  tumours,  those  of  the 
thyroid  are  frequently  submitted  to  the  operation  of  simple 
tapping  with  a  trocar  and  canula.  The  object  of  this  proceed- 
ing  is,  of  course,  to  empty  the  cyst,  and  so  to  cause  its  collapse 
and  cure.  In  many  cases  this  result  does  really  take  place,  and 
the  cure  may  be  permanent.  Not  uncommonly,  however,  a 
much  less  favourable  result  ensues.  The  cyst  rapidly  fills  again, 
this  time  u.sually  with  blood,  and  the  patient's  condition  may  be 
worse  than  it  was  before,  especially  if  the  cyst  be  large.  This 
remarkable  tendency  to  intra-cystic  haemorrhage  on  the  part  of 
thyroid  cysts  has  already  been  mentioned  in  the  chapter  on 
cystic  disease,  and  several  cases  have  there  been  related  in  which 
serious  and  even  fatal  results  have  followed  a  simple  tapping. 
The  occurrence  of  serious  harm  may  to  some  extent  be  obviated 
by  keeping  up  a  certain  amount  of  gentle  pressure  upon  the 
cyst  during  and  after  the  tapping,  so  as  to  prevent  the  sudden 
diminution  of  intra-cystic  tension.  It  must  be  borne  in  mind, 
however,  that  it  is  often  difficult  to  apply  satisfactory  pressure 
to  the  soft  yielding  structures  of  the  neck. 

For  single  cysts  of  small  size  in  which  the  walls  appear  to  be 
thin,  the  operation  of  tapping  may  be  occasionally  performed;  but 


232  THE   THYROID    GLAND. 

if  the  cvst  be  niultilocular,  or  if  it  have  thick  unvieldiiig  walls 
which  cannot  collapse,  or  if  the  contents  be  solid,  then  tapjDing 
should  not  be  attempted,  as  it  is  almost  certain  to  fail. 

It  is  occasionally  advisable  to  tap  a  thyroid  tumour  for 
diagnostic  purposes,  to  see  whether  the  contents  be  cystic  or 
solid. 

For  parenchymatous  goitres,  where  no  cysts  of  large  size  are 
present,  a  simple  tapping  is  naturally  of  no  use,  since  the  viscid 
contents  of  the  minute  intercommunicating  vesicles  drain  away 
verv  slowlv.  If,  however,  the  canula  be  left  'm  situ,  for  several 
davs  after  the  operation,  a  considerable  decrease  in  the  size  of 
the  goitre  may  occasionally  be  observed.  But  this  proceeding 
is  obWously  not  without  danger,  as  it  is  likely  to  set  up  suppura- 
tion. It  should  not  be  attempted  Avithout  due  considei'ation  of 
its  risks. 

In  any  case  in  which  tapping  is  performed  the  strictest 
attention  should  be  paid  to  asepsis. 

Tapping  of  a  goitre  of  any  kind  is  a  proceeding  which,  in  my 
opinion,  should  rarely,  if  ever,  be  adopted. 

Injection. — The  object  Avhich  is  aimed  at  in  the  injection 
of  a  goitre  is  to  cause  sufficient  inflammation  to  obliterate  some 
of  the  minute  vesicles  of  a  parenchymatous  goitre  or  the  larger 
cysts  of  a  cystic  goitre.  Possibly,  also,  there  is  some  direct 
solvent  action  upon  the  colloid  contents  of  the  vesicles,  which 
may  promote  absorption. 

It  is  obvious,  therefore,  that  parenchymatous  and  cystic 
goitres  are  more  amenable  to  ti'eatment  by  injection  than 
are  the  harder  and  more  solid  forms.  It  has  often  been  stated 
that  "fibrous"  goitres  can  be  treated  with  advantage  by  injec- 
tion, but  it  may  reasonably  be  doubted  whether  this  is  really 
the  case.  Truly  fibrous  goitres  are  by  no  means  so  common  as 
is  generally  supposed. 

Many  of  the  very  hard  goitres  which  I  have  often  seen 
diagnosed  as  fibrous  goitres  proved  eventually  to  be  parenchy- 
matous or  cystic-parenchymatous.  The  hardness  in  such  cases 
is  due  to  the  tension  of  the  fluid  within  the  small  vesicles,  or 
to  the  solidification  of  the  contents  themselves.  This  is  probably 
the  true  explanation  of  the  benefit  that  has  been  supposed  to 
result  from  injecting  so-called  fibrous  goitres. 


TREATMENT   BY    INJECTION.  233 

The  matej-'ials  that  ha\e  been  used  for  injection  are  numerous. 
The  one  which  occupies  the  foremost  rank  is  undoubtedly  iodine. 
This  may  be  used  either  in  the  form  of  simple  tincture  or  in 
combination  with  other  drugs. 

Arsenical  solutions,  perchloride  of  iron,  ergot,  osmic  acid,  and 
iodoform  have  all  been  recommended,  but  probably  not  one  of 
them  is  superior  to  iodine. 

Method  of  performing'  Injection  in  Cases  of  Par- 
enchymatous Goitre. — The  best  directions  that  I  haye  seen 
for  the  performance  of  the  injection  of  iodine  into  parenchy- 
matous goitres  are  those  giyen  by  Sir  Felix  Semon,  who  has 
written  as  follows  : 

1.  Select  suitable  cases  only,  i.e.,  cases  in  Ayhich  the  gland  sub- 
stance is  so  thick  that  one  may  be  fairly  certain  that  the  injection 
can  be  made  into  the  parenchyma  proper  and  in  which,  on  the 
other  hand^  the  interstitial  fibroid  change  has  not  progressed  too  far. 

2.  Inject  eyery  third  day  into  the  gland  substance  proper  a 
quantity  from  twenty  to  thirty  drops  of  an  alcoholic  iodine  solution 
(one  part  of  iodine  in  twelve  parts  of  absolute  alcohol)  with  a  well- 
made  and  well-cleaned  hypodermic  and  screw  syringe. 

3.  Vary  as  much  as  possible  the  place  of  injection  and  never 
inject  into  the  same  neighbourhood  on  two  consecutive  occasions. 

^.  Avoid  wounding  superficial  veins  and  injecting  air.  A  piece 
of  tape  may  be  tied  round  the  neck  below  the  tumour  so  as  to  com- 
press the  superficial  veins. 

5.  Neither  insert  the  point  of  the  needle  too  timidly,  when  the 
injection  fluid  will  very  likely  pass  into  the  cellular  tissue^  suppura- 
tion resulting  ;  nor  too  violently,  when  it  may  completely  perforate 
the  gland  and  the  injected  fluid  may  be  thrown  into  other  impor- 
tant tissues.  It  is  a  good  plan  to  let  the  patient  swallow  when 
the  needle  has  been  inserted,  before  the  injection  is  proceeded 
with,  the  body  of  the  syringe  being  held  quite  loosely  in  the 
operator's  hand  ;  if  the  point  of  the  needle  is  in  the  gland  substance 
the  foremost  point  of  the  syringe  will  rise  with  the  rising  gland  ;  if  it 
be  in  front  of  the  gland  no  movement  will  ensue ;  if  it  have  per- 
forated the  gland  the  hindermost  part  of  the  syringe  will  chiefly  rise. 

6.  Never  inject  in  such  a  direction  that  the  point  of  the  needle 
points  directly  towards  the  trachea  or  towards  the  great  vessels  and 
nerves  of  the  neck. 

7.  Inject  very  slowly  and  watch  especially  the  effect  of  the 
injection  of  the  first  few  drops.     Select  the  place  of  injection  care- 


234  THE    THYROID    GLAND. 

fully  beforehand  by  palpation  and  steady  the  tumour  with  the  left 
hand  whilst  making  the  injection.  Previous  freezing  of  the  surface 
with  anaesthetic  ether*  round  the  point  selected  for  injection  may 
l)e  resorted  to,  but  is  not  necessary. 

That  the  directions  given  above  are  excellent,  there  can,  I 
think,  be  little  doubt ;  and  any  one  who  is  about  to  treat  a 
goitre  by  injection  of  iodine  cannot  do  better  than  follow 
them. 

There  can  also  be  but  little  doubt  that  in  a  large  number  of 
cases,  a  successful  result  ensues,  at  any  rate,  for  a  time.  There 
is,  however,  equally  little  doubt  that  very  often  the  treatment 
is  unsuccessful.  A  considerable  number  of  cases  have  been 
recorded  in  which  various  complications,  including  death  itself, 
have  folloAved  the  operation. 

The  injection  may,  and  in  most  cases  probably  does,  at 
first  produce  increased  swelling  of  the  gland.  This  may  cause 
dyspnoea  or  aggravate  that  which  is  already  present.  The  injec- 
tion may  cause  suppuration,  which  in  its  turn  may  lead  to  death. 

Obalinski  relates  the  case  of  a  man  who  had  a  large  goitre  ;  a 
single  injection  of  iodine  caused  suppuration,  together  with 
such  increase  in  the  size  of  the  tumour  that  it  was  deemed 
necessary  to  remove  part  of  it.  The  man  died  of  pyaemia  on 
the  tenth  dav. 

Liebrecht  relates  a  case  which  occurred  in  the  practice  of 
Dr.  Albert  of  Innsbriick;  injections  of  iodine  into  the  goitre 
led  to  suppuration  and  other  severe  symptoms  ;  the  tumour  was 
remoA-ed  but  the  patient  succumbed. 

Instances  such  as  the  above  are  numerous,  and,  were  it 
necessary,  many  more  might  be  cited  here. 

In  the  above  cases  the  evil  results  were  due  to  inflammation 
and  suppuration  occurring  in  the  neck. 

A  considerable  number  of  cases  have,  however,  been  recorded 
in  which  death  ensued  much  more  speedily,  before  suppuration 
had  had  time  to  manifest  itself. 

Dr.  Rose,+  formerly  of  Zurich,  says  that  he  himself  knows  of 

*  This  was  written  before  tlie  introduction  of  cocaine  and  eucaine  as  local 
anaesthetics  ;  at  the  present  day  these  would  be  preferred. 

t  '-Der  Kropftod  und  die  Eadicalcur  der  Kropfe,"  Archiv  f.  liUn.  Chir. 
vol.  xxii. 


TREATMENT   BY    INJECTION.  235 

not  less  than  six  cases  in  which  surgeons  have  lost  healthy 
patients  from  injection  of  iodine  into  a  goitre,  death  occurring 
either  upon  the  operating  table  or  within  a  few  hours  of  the 
injection. 

Dr.  Johannes  Seitz,*  in  a  monograph  upon  death  from  goitre, 
mentions  the  following  cases  : 

The  first  is  that  of  a  woman  under  the  care  of  Dr.  Schwalbe  ;  the 
injection  of  ten  drops  of  tincture  of  iodine  into  a  small  goitre  caused 
after  a  few  minutes  numbness  and  then  paralysis  of  the  left  arm 
and  leg,  partial  loss  of  speech,  slight  facial  paralysis,  general  convid- 
sions  and  death  at  the  end  of  twenty  hours.  No  post-mortem 
examination  was  made.  After  this  case  Dr.  Schwalbe  gave  up  the 
use  of  iodine  injections  and  employed  alcohol  instead. 

The  next  case  is  that  of  a  young  woman  into  whose  goitre  iodine 
had  many  times  been  injected ;  after  the  last  injection  she  took 
violent  exercise  for  some  hours  ;  the  tumour  then  began  to  cause 
great  pain  ;  the  goitre  became  greatly  swollen,  and  in  three  days 
the  patient  was  dead. 

The  third  case  occurred  in   the  practice  of  Dr.  K.  St .     The 

patient  was  a  woman  of  27,  the  goitre  was  as  large  as  a  small  apple, 
moderately  hard,  and  affecting  the  right  lobe  of  the  gland.  A 
common  Pravaz  syringe  of  small  size  was  three-quarters  filled  with 
tincture  of  iodine^  and  the  injection  made  in  the  ordinary  manner. 
Immediately  after  the  injection  the  patient  complained  of  pain  in  the 
right  eye.  She  then  began  to  sway  about  in  her  chair,  and  quickly 
lost  all  power  of  speech.  The  right  upper  and  lower  eyelids  became 
cedematous,  and  the  right  eye  appeared  to  be  pushed  forwards.  In 
the  right  half  of  the  face  appeared  several  blue  spots,  which 
increased  in  size  until  death  occurred.  In  the  first  half-hour  she 
was  very  restless,  then  became  more  quiet ;  the  breathing  was  quiet 
and  regular,  the  pulse  rather  slow  (48  to  50).  The  pupils  were 
natural,  and  there  was  no  facial  paralysis.  The  patient  remained  in 
the  above  condition  for  about  three  hours  ;  then  the  pulse  became 
much  more  rapid,  and  breathing  became  deeper  and  irregular 
Death  occurred  eight  hours  after  the  injection. f 

The  post-mortem  examination  was  unsatisfactory.  In  the  vessels 
of  the   brain  and  its   membranes  no   thrombosis  or  embolism  was 

*  ••  Der  Kropftod  durch  Stinimbtindlahmung,"  Langenbeck's  Archlrf.  Idin. 
Chir.  xxix.  1. 

t  Dr.  K.  St.  alludes  to  another  case  which  appears  to  have  occurred  at 

Berne  and  in  which  similar  sj^mptoms  occurred  ;  no  particulars,  however,  are 
given. 


236  THK   THYROID    GLAND. 

found ;  on  section  the  right  side  of  the  brain  showed  numerous 
bloody  points ;  the  choroid  plexus  was  of  a  darker  colour  than 
natural.  Several  ounces  of  serous  fluid  were  found  in  the  pleural 
and  pericardial  cavities.  The  goitre  was  chiefly  ])arenchymatous, 
but  contained  also  a  small  cyst,  of  the  size  of  a  hazel  nut,  in  the 
posterior  wall  of  which  was  a  large  vein^  into  which  it  seemed 
possible  that  the  iodine  had  been  injected.  Chemical  examination 
of  the  contents  of  the  cyst  showed  no  iodine  to  be  present. 

In  1884,  Dr.  Krieg  *  related  to  the  Medical  Society  of 
Stuttgard,  a  case  in  which  sudden  death  had  followed  the  injec- 
tion of  two  drops  of  tincture  of  iodine  into  a  goitre  : 

The  patient  was  a  cretinous  girl,  aged  fifteen.  D^'spnoea  had 
been  present  for  many  years,  but  had  increased  considerably  in  the 
last  fortnight.  Two  drops  of  tincture  of  iodine  were  injected  into 
the  middle  of  the  goitre  and  the  syringe  withdrawn.  In  less  than 
a  minute  the  dyspnoea  becaine  nciuch  more  severe,  and  the  right 
side  of  the  neck  began  to  swell.  The  child  became  livid,  lost  con- 
sciousness, and  in  two  minutes  was  dead. 

At  the  post-mortem  examination  it  was  found  that  the  goitre 
consisted  of  a  nodule  as  large  as  a  hen's  egg,  involving  the  I'ight 
lobe  of  the  thyroid  gland.  The  injection  had  been  made  quite 
correctly  into  the  centre  of  it.  The  small  wound  made  by  the 
syringe  had  led,  however,  to  considerable  haemorrhage  into  the 
tissues  between  the  tumour  and  its  capsule.  The  extravasated 
blood,  pressing  upon  the  already  much  narrowed  trachea,  and  upon 
other  surrounding  structures,  had  been  sufficient  to  cause  death. 
The  trachea  opposite  its  second,  third  and  fourth  rings  was  so 
narrow  that  its  walls  were  almost  in  contact.  It  was  found,  however, 
that  this  extreme  narrowing  was  due,  not  merely  to  the  pressure  of 
the  goitre,  but  also  to  the  presence  of  a  firm  papillomatous  fibrous 
tumour,  which  grew  from  the  left  wall  of  the  trachea  and  filled  up 
more  than  half  its  lumen. 

These  cases  show  pretty  clearly  that  injection  of  iodine  into 
a  parenchymatous  or  adenomatous  goitre,  is  an  operation  by  no 
means  devoid  of  danger,  even  when  performed  carefully,  and 
when  only  a  small  quantity  of  fluid  is  injected,  as  in  Krieg's 
case. 

*  ■■  Kotzliclier  Tod  durch  purencliymatose  Injection  von  lodtinctur  in  einen 
librosen  Kropf . "  Mediz.  €uri-esj)on(l.  Bl.  d.  Wiliiteinh.  aer:tJ.  Za/idrsve):,iitutt- 
gard,  1884,  liv.  pp.  145-149. 


TREATMENT   BY    INJFXTIOX.  237 

Professor  v.  Mosetig-Moorhof  *  advocates  the  injection  of  a 
solution  of  iodoform  for  the  treatment  of  soft  parenchymatous 
goitres.  Formerly  he  used  tincture  of  iodine  but  this  caused 
suppuration  in  one  of  his  cases.  He,  therefore,  gave  up  the  use 
of  it  and  used,  instead,  one  of  the  following  solutions  : 

Iodoform     ....       1  gramme  "j  [1  gramme 

Ether  .  .  .  .       ')  grammes  .•  or  -  7  grammes 

Olive  oil      .  .  .  -       9  grammes  j  [7  grammes. 

The  solution  should  be  freshly  prepared,  and  is  then  of  a  light 
yellow  colour  and  transparent.  On  exposure  to  light  it  is  apt 
to  become  brown  from  liberation  of  free  iodine,  and  should  not 
then  be  used.  It  should  therefore  be  kept  in  the  dark  when 
not  required  for  use.  v.  Mosetig-Moorhof  injects  one  gramme 
(15  minims)  or  more  at  a  time,  and  usually  makes  from  five  to 
ten  injections  in  each  case.  The  reaction  after  each  injection  is 
usually  very  slight  and  does  not  prevent  the  patients  from 
following  their  ordinar\'  occupations. 

He  has  performed,  altogether,  some  -100  injections  upon 
seventy-nine  patients,  and  says  that  he  has  always  succeeded  in 
reducing  the  size  of  the  swelling.  He  has  never  had  any  bad 
result.  He  recommends  this  treatment  only  for  soft  parenchy- 
matous goitres,  and  not  for  the  fibrous,  cystic,  or  any  other 
kind. 

Injection  of  Cystic  Goitre. — For  the  injection  of  cystic 
goitre,  iodine  has  been  largely  employed.  It  is  open  to  the 
same  objections  that  have  been  mentioned  in  connection  with 
the  injection  of  parenchymatous  goitre.  The  use  of  perchloride 
of  iron,  instead  of  iodine,  has  been  recommended  for  cystic 
goitre,  and  is  often  employed.  The  chief  advantage  of  employ- 
ing perchloride  of  iron  is  that  haemorrhage  is  more  readily 
checked.  The  injection  of  perchloride  of  iron  has  been 
especially  advocated  in  England  bv  Sir  Morell  Mackenzie, f  and 
as  his  description  of  the  method  is  the  best  with  which  I  am 
acquainted,  the  directions  that  he  gives  may  be  quoted  here : 

"The  cyst  is  first  punctm*ed  and  emptied  with  a  trocar  at  its 
most  dependent  part,  a  drachm  or  two  of  the  solution  of  perchloride 

*   Wiejie?-  Med.  Presse,  1890,  xsxi.  p.  1. 

J  Heatli's  "  Diet,  of  Sm"gery,"  Art.  Diseases  of   Thyroid  Gltxud. 


238  THE   THYROID    GLAND. 

of  iron*  is  then  injected,  the  canula  with  its  plug  and  the  iron 
solution  being  left  in  the  cyst.  After  twenty-four  hours  the  plug 
is  removed,  and  the  contents  of  the  cyst  withdrawn.  If  the  fluid 
be  then  found  to  contain  much  blood,  or  if  it  be  thin  and  sei'ous  in 
appearance,  a  second  injection  must  be  made.  In  other  words, 
while  ha?morrhage  must  be  carefully  prevented,  a  slight  inflamma- 
tion of  the  lining  membrane  of  the  cyst  is  essential.  One  injection 
is  generally  sufl5cient,  but  if  the  first  injection  fluid  be  too  quickly 
removed,  the  process  may  have  to  be  repeated  three  or  four  times 
at  intervals  of  two  or  three  days.  When  reaction  has  taken  place 
and  the  discharge  is  free  from  blood,  the  canula  with  its  plug  must 
still  be  kept  in  the  cyst.  Poultices  of  linseed  meal  should  be  kept 
constantly  applied  for  three  or  four  weeks,  sometimes  longer. 
When  suppuration  is  well  set  up  the  plug  may  be  removed  ;  the 
canula,  however,  being  allowed  to  remain  until  the  secretions 
become  limited  in  amount  and  thin  in  consistence.  When  the  cyst 
is  A^ery  large  it  is  best  to  try  to  reduce  the  quantity  of  fluid  before 
injecting.  This  can  often  be  done  by  drawing  off  a  small  amount, 
say  two  or  three  drachms,  at  intervals  of  a  day  or  two  on  several 
occasions.  No  attempt  must,  however,  be  made  to  empty  the  sac 
entirely,  for  if  this  is  done  haemoi-rhage  takes  place  from  the  lining 
membrane  of  the  cyst  into  its  cavity,  which  soon  becomes  full 
again.  The  duration  of  the  treatment  is  from  three  weeks  to  four 
months,  according  to  the  size  of  the  cyst,  the  usual  time  being  six 
to  eight  weeks." 

Those  who  desire  further  information  concernino-  the  details 
of  Mackenzie's  method  of  treating  thyroid  cysts  will  do  well  to 
read  a  paper  by  Mr.  Mark  Hovell  on  the  treatment  of  cvstic 
goitre,  "f 

I  have  never  employed  this  method  myself,  as  I  consider  it  to 
be  too  dangerous.  Suppuration  appears  to  be  a  necessary  part 
of  the  curative  process,  and  having  been  once  started,  may  be 
very  difficult  to  control.  It  is  veiy  apt  to  lead  to  death  from 
septic  absorption.  The  dangers  of  suppurating  goitre  are, 
however,  too  well  known  to  require  further  comment. 

Although  there  can  be  no  doubt  that  this  method  does,  in 
many  cases,  effect  a  cure,  yet  there  is  equally  little  doubt  that 
it  often  fails.  Either  the  patient  is  left  with  a  fistula  or  the 
tumour  returns  after  a  while.     A  more  or  less  permanent  fistula 

*  A  watery  2.5  per  cent,  solution  of  perchloride  of  iron  is  used, 
t  Lancet,  1888.  p.  264. 


TREATMENT    BY    INXISIOX. 


139 


is  especially  likely  to  be  produced  if  the  walls  of  the  cvst  be 
firm  and  unyielding.  Of  this  I  have  seen  several  distressing 
examples.     (Fig.  86.) 

Another  objection  to  injecting  encapsuled  thyroid  tumours  is 
that  if  the  injection 
fails  to  cure,  and  enu- 
cleation becomes  neces- 
sary, the  latter  opera- 
tion mav  be  rendered 
more  difficult  owing  to 
the  adhesions  set  up 
round  the  tumour. 
Some  of  the  most 
troublesome  enuclea- 
tions that  I  have  had 
to  perform  have  been 
in  cases  in  which  injec- 
tion had  previously 
been  perform  ed .  Never- 
theless, the  method  has 
its  advantages.  It  is 
simple  and  requires  no 
oTeat  knowledge  of 
aseptic  surgery  for  its 
performance.  ^lore- 
over,  if  successful,  the 
scar  that  is  left  may 
be  much  smaller  than 
that  produced  by  any  cutting  operation. 

At  the  present  day  this  method  of  treating  thvroid  cvsts  is 
employed  chiefly  by  those  who  are  not  familiar  with  the  details 
of  modern  aseptic  surgery,  and  upon  those  who.  being  exceed- 
ingly anxious  to  avoid  a  linear  scar,  are  willing  to  incur  a  greater 
risk  in  order  to  attain  this  object. 

Incision. — Direct  incision  of  a  goitre  is  a  method  em])loyed 
chiefly  in  cases  of  cvsts  and  is  of  very  limited  applicability. 
The  practice  of  incising  thyroid  cysts,  and  stitching  their  cut 
edges  to  those  of  the  skin,  is  one  which  has  now  been  almost 
entirely  superseded  by  the  much  safer  and  more  rapid  method 


Fig.  se. — A  mau  in  whom  a  cystic  yoitre  had  been 
tapi^ed  aud  injected  some  years  previonsly  (at 
another  hospital ).  A  fistulous  opening-  had  existed 
ever  since  the  operation.     (Seen  at  St.  Bart.  Hosp. 

in  1S86.1 


040  THE   THYROID    GLAND. 

of  enucleation.  It  is  still,  however,  to  be  recommended  for 
certain  cases  in  which,  from  old  or  recent  inflammation  or  other 
cause,  the  cyst  is  too  adherent  to  surrounding  parts  to  permit 
of  enucleation.  Some  cases  of  suppurating  goitre  have  to  be 
treated,  at  any  rate  at  first,  by  incision.  Enucleation  or  extir- 
pation may  have  to  be  undertaken  later. 

Incision  of  the  isthmus  as  a  means  of  treating  parenchymatous 
goitre  will  be  discussed  separately  in  the  next  chapter. 

Seton. — A  method  of  treatment  of  goitre  formerly  much  in 
vogue,  but  now  happilv  becoming  obsolete,  is  that  of  the  intro- 
duction of  a  seton.  A  piece  of  silk  or  some  similar  material  is 
passed  right  through  the  substance  of  the  goitre  and  left  in  situ 
for  days  or  weeks.  Usually  the  goitre  shrinks  in  size  and  may 
become  permanently  cured. 

This  method  is  obviously  open  to  two  serious  objections. 

First,  there  is  considerable  danger  of  transfixing  some  large 
vein  and  thus  causing  serious  or  fatal  haemorrhage. 

Secondly,  there  is  very  serious  risk  of  setting  up  septic  inflam- 
mation in  the  goitre,  and  in  the  cellular  tissue  of  the  neck,  and 
this,  in  its  turn,  is  very  likely  to  lead  to  pyaemia. 

A  case,  illustrating  this  latter  danger,  has  been  kindly  com- 
municated to  me  by  Dr.  Bankart  of  Exeter : 

A  young  man  had  a  goitre^  probably  parenchymatous  in  nature, 
into  which  a  seton  was  inserted  on  account  of  the  dyspnoea  from 
which  he  was  suffering.  Suppuration  in  the  neck  and  mediastinum 
quickly  ensued  ;  necrosis  of  several  rings  of  the  trachea  took  place 
and  the  patient  died. 

In  the  museum  of  the  Koyal  College  of  Surgeons  is  a  speci- 
men *  of  a  thyroid  cyst  some  three  inches  in  diameter.  "  A 
seton  introduced  through  the  cyst  by  the  surgeon  in  attend- 
ance caused  diffuse  inflammation,  resulting  in  the  death  of  the 
patient.'"' 

There  is  also  a  similar  specimen  in  the  museum  of  St.  George's 
Hospital. f 

A  seton  is  probably  more  efficacious  in  the  case  of  a  cystic 
goitre  than  in  that  of  a  parenchymatous  one.  In  the  former 
case,  the  fluid  would  be  drained  away  by  the  side  of  the  seton. 

*  Xo.  2yu4.  t  Xo.  20a. 


LIGATURE    OF    THYROID    ARTERIES.  i>41 

The  method  is,  however,  too  dangerous  to  warrant  its  recom- 
mendation for  anv  kind  of  goitre. 

liig-ature  of  Thyroid  Arteries, — This  operation  has 
been  recommended  and  performed  manv  times  in  the  hope  that 
by  cutting  off  the  blood  supply  to  the  goitre,  its  size  might  be 
diminished. 

The  operation  is  bv  no  means  a  new  one. 

In  1814,  Walther  *  of  Landshut  tied  both  superior  thvroid 
arteries  in  a  voung  man,  the  subject  of  dvspuoea  caused  bv 
goitre. 

Four  years  later,  Mr.  Coates  of  Salisbury  tied  the  left 
superior  thyroid  in  a  similar  case.  In  a  case  of  Sir  William 
Blizard's,  the  operation  was  followed  bv  sloughing  and  death 
from  secondary  haemorrhage. 

McWhinnie,+  in  his  lectures  upon  goitre,  delivered  at  the 
Roval  College  of  Surgeons,  mentioned  a  case  in  which  ]Mr.  Earle 
tied  this  artery,  at  St.  Bartholomew's  Hospital. i;  Giinther  has, 
according  to  Liebrecht,  collected  twenty-one  cases  of  ligature  of 
the  superior  th\Toid  artery  for  the  cure  of  goitre.  In  two  cases 
a  cure  is  said  to  have  been  the  result ;  in  fourteen  there  was 
some  improvement ;  in  two  there  was  none,  and  in  three  death 
ensued.  All,  or  nearly  all,  the  preceding  cases,  occurred  before 
the  days  of  antiseptic  surgery.  In  all  of  them  it  was  the  thvroid 
artery  alone  that  was  tied,  on  one  or  on  both  sides  of  the 
body. 

For  manv  years  the  operation  was  completely  out  of  fashion,. 
and  was  ne\"er  performed. 

Of  late  years,  however,  it  has  been  revived  by  Wolfler  and 
Billroth,  who  have  recommended  that  not  only  the  superior  but 
also  the  inferior  thyroid  arteries  should  be  tied.  By  this  means 
the  blood  supply  to  the  gland  is  cut  off  far  more  effectually 
than  by  ligature  of  the  superior  arteries  alone,  which  are  con- 
siderably smaller  than  the  inferior. 

Ligature  of  the  superior  thvroid  arteries  was  recommended 

*  "  Xeiie  Heilart  des  Kropf es  durcli  die  Unterhindiuig  der  oberen  Schiag- 
adern,"  Salzbach.  1817.  p.  2.5,  quoted  in  Cooper's  Diet,  of  Surgery. 

t  Lancet  1861,  ii.  30. 

J  See  also  cases  by  Dowries  at  the  Kashmir  Hospital.  Lanref.  1881.  i.  4.58  ; 
temporary  benefit  is  said  to  have  occm-red. 

II  •■  De  Texcision  du  goitre  parench}-mateux,''  1883,  170. 


24'2  THE   THYROID    GLAND. 

largely  on  the  ground  that  it  is  a  simple  operation  and  tolerably 
easy  to  perform  The  same  argument  can  hardly  be  urged  in 
favour  of  ligature  of  the  inferior  thyroid  arteries.  From  their 
deep  situation,  lying  as  they  do  upon  the  vertebral  column  at 
the  back  of  the  goitre,  and  from  their  close  proximity  to  the 
sympathetic  nerve,  it  is  evident  that  the  operation  of  tying 
them  is  one  of  much  difficulty ;  in  fact  it  may  be  more  difficult 
than  that  of  removal  of  the  goitre. 

\'ahiable  information  upon  the  subject  of  simultaneous  ligature 
of  both  superior  and  inferior  thyroid  arteries,  is  to  be  found  in 
two  papers  by  Rydygier  *  of  Ci'acow.  He  publishes  sixteen 
cases  in  which  he  had  performed  the  operation.  In  the  first  case, 
the  two  arteries  were  tied  only  on  one  side  of  the  neck.  In  the 
others  all  four  arteries  were  tied  at  one  operation.  He  operated 
by  Drobnik's  method  at  the  posterior  border  of  the  sterno- 
mastoid  in  all  cases  except  the  last  two ;  in  these  he  used  a 
horizontal  incision  in  order  that  the  scar  might  be  less  visible. 
All  the  wounds,  with  one  exception,  were  treated  without 
drainage.  The  results  were  good  in  all  cases  except  two.  One 
of  these  was  that  in  which  the  arteries  of  the  right  side  only 
had  been  tied ;  only  slight  diminution  occurred  in  the  size  of 
the  goitre,  which  was  a  parenchymatous  one.  The  other  case 
was  one  in  which  one  lobe  only  of  the  gland  diminished  in  size 
and  it  was  then  discovered  that  the  opposite  lobe  contained  a 
cyst.  This  was  subsequently  enucleated  and  the  patient  made 
a  good  recovery.  In  one  case  only  did  troublesome  haemorrhage 
occur.  In  this  case  the  right  superior  thyroid  artery  gave  way 
while  the  ligature  was  being  placed  upon  it.  Violent  haemor- 
rhage took  place,  and  could  be  controlled  only  by  leaving 
pressure  forceps  in  the  wound  for  more  than  a  week.  The 
patient  eventually  made  a  good  recovery,  and  the  goitre  dimin- 
ished in  size.  In  several  cases  there  was  a  slight  rise  in  tempera- 
ture (in  one  case  up  to  102'),  but  this  quickly  subsided. 

Rydygier  discusses  the  question  whether  it  is  enough  to  tie 
the  arteries  on  one  side  of  the  neck  only,  and  expresses  himself 
strongly  in  favour  of  simultaneous  ligature  of  all  four  arteries. 

Whether  the  operation  can  lead  to  the  subsequent  occurrence 
of  cachexia  strumipriva  is  a  point  which  seems  doubtful. 

.  *  OmtralUaftf.  Chir.,  1889,  p.  2-1:1. 


LIGATURE   OF   THYROID   ARTERIES.  243 

The  cases  that  appear  to  be  most  suitable  for  ligature  of  the 
thyroid  arteries  are  early  cases  of  parenchymatous  enlargement 
and  cases  of  exophthalmic  goitre.  With  regard  to  the  former, 
however,  it  seems  to  be  better  to  treat  them  by  medical  means 
or,  if  operation  is  demanded,  to  do  some  more  radical  operation 
such  as  unilateral  extirpation  or  resection,  the  results  of  which 
are  extremely  satisfactory.  Ligature  of  the  thyroid  arteries  for 
exophthalmic  goitre  has  received  the  support  of  Kocher,  who  is, 
however,  in  favour  of  tying  three  only  of  the  four  arteries. 

It  is  obviously  useless  to  treat  cases  of  cystic,  fibrous,  or 
fibro-adenomatous  goitre  by  ligature  of  the  arteries. 

Ligature  of  the  superior  thyroid  artery  is  best  per- 
formed through  an  incision  along  the  anterior  border  of  the 
sterno-mastoid  opposite  the  great  cornu  of  the  hyoid  bone. 
The  artery  may  be  tied  either  near  the  tip  of  the  great  cornu  of 
the  hyoid  or  at  the  inner  edge  of  the  omo-hyoid  muscle.  The 
latter  method  is  said  to  be  the  better  when  the  goitre  is  large 
and  the  artery  consequently  much  displaced.  The  apex  of  the 
upper  horn  of  the  gland  is  naturally  a  good  guide  to  the 
vessel. 

Ligature  of  the  inferior  thyroid  artery  is  much  more 
difficult.  This  operation  may  be  performed  by  one  or  other  of 
three  principal  methods. 

(1)  Internal  to  the  sterno-mastoid  (Velpeaa's  method).  An 
incision  is  made  along  the  anterior  border  of  this  muscle.  The 
veins  passing  from  the  thyroid  gland  to  the  internal  jugular  vein 
are  tied  and  divided.  The  carotid  sheath  is  drawn  outwards 
away  from  the  gland.  The  thyroid  artery  is  then  found  at  the 
inner  border  of  the  scalenus  anticus  muscle.  The  artery  should 
be  tied  just  where  it  changes  its  direction  from  the  vertical  to 
the  horizontal. 

This  operation  is  usually  difficult.  Many  veins  have  to  be 
tied.  The  artery  is  much  overlapped  by  the  goitre.  The  latter 
has  to  be  lifted  up  out  of  its  bed  before  the  artery  can  be 
exposed. 

(2)  Through  the  sterno-mastoid  (Langenbeck's  method,  modi- 
fied by  Wolfler).  The  incision  is  made  over  the  sterno-mastoid. 
Its  lower  end  is  at  the  junction  of  the  inner  sixth  of  the  clavicle 
with  the  remainder.     The  fibres  of  the  muscle  must  be  partially 


244  THE   THYROID    GLAND. 

divided.  Several  large  veins,  including  the  external  jugular, 
usual Iv  require  ligatui'e.  Search  is  now  made  for  the  tendinous 
part  of  the  onio-hyoid,  an  important  guide  to  the  artery.  The 
tendon  is  drawn  upwards  or  divided.  The  carotid  sheath  is 
drawn  inwards,  the  phrenic  ner\e  outwards.  The  artery  is  then 
seen  Iving  at  the  inner  edge  of  the  scalenus  anticus.  If  necessary 
this  muscle  must  he  drawn  a  little  outwards. 

(3)  Ej'tcrnal  to  the  sterno-mastoid  (Drobnik's  method,*  as 
practised  bv  Rydvgier).  This  appears  to  be  the  best  method, 
at  any  rate  for  cases  in  which  the  gland  is  much  enlarged. 

The  incision  is  made  at  the  posterior  border  of  the  sterno- 
mastoid.  It  begins  at  the  clavicle  or  a  little  above  it  and  is 
carried  upwards  to  the  point  at  which  the  external  jugular  vein 
crosses  the  posterior  border  of  the  sterno-mastoid,  usually  on  a 
level  with  the  lower  border  of  the  thyroid  cartilage.  The 
sterno-mastoid  muscle  and  carotid  sheath  are  drawn  inwards  and 
the  arterv  found  as  above.  It  is  best  tied  immediately  above 
the  place  where  it  is  crossed  by  the  omo-hyoid  muscle. 

Rvdygier"*"  has  proposed  a  slight  modification  of  Drobnik's 
original  operation.  He  makes  the  skin  incision  not  vertically, 
but  horizontal Iv,  a  little  above  the  clavicle.  By  this  means  the 
«car  is  rendered  less  visible. 

Exothyropexy. — ^This  operation  consists  in  cutting  down 
upon  the  thvroid  gland,  dislocating  it  through  the  wound,  and 
then  leaving  it  exposed  to  the  air. 

It  has  a  twofold  object,  that  of  mechanically  relieving  the 
tracheal  pressure  and  that  of  inducing  atrophy  of  the  exposed 
gland. 

First  practised  bv  Jaboulay  of  Lyons  in  1892,  the  operation 
has  been  performed  much  more  often  in  France  than  in  any 
other  country.  It  is  especially  at  Lyoiis  that  it  is  apparently  in 
greatest  favour.  Our  knowledge  of  it  is  due  mainly  to  the 
experience  of  the  surgeons  of  that  town.  In  this  country  exo- 
thyropexy has  not  become  popular,  and  it  does  not  seem  to  me 
at  all  likely  that  it  ever  will. 

The  best  account  of  exothyropexy  that  has  come  under  mv 
notice  is  that  of  Dr.  Leon  Berard,  who  in  his  excellent  work   on 

*   Wien.  nted.   Wochenschr.,  1887.  p.  (35. 
J  Cent ralMatt  fur  Chirurgie.  188'J.  p.  241. 


EXOTHYROPEXY.  245 

goitre  *  has  published  many  cases  of  exothyropexy  ;  nearly  all 
of  these  occurred  at  Lyons  in  the  practice  of  Poncet,  Jaboulay, 
and  their  colleagues. 

The  operation  has  been  performed  upon  various  kinds  of 
goitre.  It  appears  to  have  been  performed  most  often  upon,  and 
to  be  most  suitable  for,  the  more  solid  and  vascular  forms  of 
parenchymatous  goitre  and  exophthalmic  goitre.  It  is  intended 
to  obviate  the  risks  of  extirpation  of  such  goitres.  The 
proceeding  has,  however,  risks  of  its  own,  and  the  objections  to 
it  are  considerable  and  obvious.  I  have  never  mvself  performed 
an  exothyropexy,  believing  extirpation,  if  properlv  performed, 
to  be  a  safer,  more  satisfactory,  and  altogether  better  operation. 
The  principal  objections  to  exothvropexv  are  the  mechanica 
,  difficulties  of  effecting  the  dislocation  in  cases  in  which  the 
goitre  is  deeply  seated  and  causing  much  dyspnoea,  the  risk  of 
venous  haemorrhage  and  sepsis,  the  long  time  occupied  bv  the 
healing  process,  the  liability  to  recurrence,  and  the  verv  con- 
siderable deformity  which  is  necessarily  produced  bv  the  opera- 
tion. The  cases  in  which  it  is  most  likely  to  be  justifiable  seem 
to  me  to  be  those  of  prominent  and  bilateral  goitres  of  a  paren- 
chymatous nature,  in  patients  who  are  not  suffering  urgently 
from  dyspnoea,  and  who  do  not  object  to  the  unsightly  ap])ear- 
ance  of  the  resultino-  scar. 

It  may  perhaps  be  justifiable  in  certain  unusual  forms  of 
prominent  exophthalmic  goitre  of  large  size. 

It  has  also  the  advantages  of  being  usually  a  short  operation 
and  one  which  requires  very  little  of  that  exact  knowledge  of 
anatomy  so  essential  for  the  successful  performance  of  extiroa- 
tion. 

Method  of  Operating. — A  median  incision  of  suitable  length 
is  made  in  the  middle  line  of  the  neck.  This  should  extend 
downwards  as  far  as  the  episternal  notch.  Any  large  superficial 
veins  that  may  be  encountered  are  clamped,  cut,  and  tied.  The 
incision  is  carried  through  the  skin,  fascia  and  layers  of  cellular 
'tissue,  until  the  capsule  of  the  gland  has  been  exposed.  The 
wound  is  then  enlarged  with  the  fingers,  which  are  insinuated 
gently  between  the  surface  of  the  goitre  and  the  superficial 
tissues  until  the  lateral  borders  of  the  goitre  have  been  reached. 
*  ■•  Therapeutique  chirurgicale  du  goitre."  Paris.  1897. 


2i6  THE   THYROID   GLAND. 

At  this  stage  no  instruments  should  be  used  for  fear  of  tearing 
or  cutting  veins  and  other  important  structures.  If,  owing  to 
the  size  of  the  goitre,  the  fixity  of  the  structures  over  it,  or  any 
other  reason,  the  edges  of  the  goitre  cannot  easily  be  reached 
with  the  fingers,  the  operator  must  not  hesitate  to  divide  trans- 
versely the  skin  and  muscles,  so  as  to  give  more  room.  Each 
lateral  lobe  of  the  goitre  has  now  to  be  dislocated  forwards. 
This  is  effected  by  hooking  one  or  more  fingers  round  the 
external  border  of  the  lobe  and  then  drawing  it  forwards.  As 
a  rule  each  lateral  lobe  must  be  dislocated  separately,  one  after 
the  other.  Occasionally  it  is  possible  to  dislocate  both  lobes 
simultaneously  by  Avidely  opening  the  wound  with  the  thumbs, 
while  pressure  is  exerted  upon  the  back  of  the  lobes  by  fingers 
placed  upon  the  skin  at  the  sides  of  the  neck.  This  proceeding, 
however,  exposes  the  trachea  to  serious  risk  of  dangerous  or 
even  fatal  compression.  The  moment  of  affecting  the  dislocation, 
even  of  one  lobe,  is  always  a  dangerous  one,  owing  to  the  increased 
pressure  exerted  upon  the  trachea.  The  greatest  care  should  be 
taken  that  the  thyroid  gland  itself  or  the  thyroid  veins  be  not 
torn  by  the  fingers.  The  fingers  should  be  inserted  at  the  sides 
of  the  gland,  and  not  beneath  its  lower  horn,  where  the  veins 
are  usually  large  and  numerous.  The  fingers  must  never 
penetrate  the  thyroid  capsule. 

The  goitre  having  been  dislocated,  strips  of  sterilised  gauze 
are  now  packed  round  the  tumour  in  the  cleft  between  the 
goitre  and  the  edges  of  the  skin  wound.  An  antiseptic  dressing 
is  then  placed  over  the  whole  of  the  exposed  surface  of  the 
o-oitre. 

The  strips  of  gauze  which  have  been  placed  in  the  grooves 
between  the  goitre  and  the  edges  of  the  skin  are  intended  to 
protect  the  mediastinum  from  infection  by  the  fluids  which 
exude  abundantly  at  first  from  the  exposed  surface  of  the  gland. 
These  strips  may  be  removed  on  the  fourth  day  and  need  not 
be  replaced.  The  skin  is  then  allowed  to  unite  with  the  goitre, 
and  gradually  re-covers  it.  Great  care  must  be  taken  to  keep 
the  whole  of  the  exposed  surface  aseptic  during  the  process  of 
cicatrisation.  "  Cutaneous  cicatrisation  is  complete,  on  the 
average,  by  the  end  of  six  weeks  or  two  months."* 

*  Berard,  op.  rit.  p.  .321. 


EXOTHYROPEXY.  247 

During  the  first  few  davs  after  the  operation  there  is  a 
copious  exudation  of  serous  fluid  from  the  exposed  surface  of 
the  gland.  This  exudation  comes  partly  from  torn  lym- 
phatics, partly  from  the  tui'gid  veins  compressed  by  the  edges  of 
the  cutaneous  wound,  and  consists  also  in  part,  no  doubt,  of 
the  colloid  secretion  of  the  gland  itself. 

After  a  day  or  two  the  veins  on  the  surface  of  the  tumour, 
which  are  at  first  swollen  and  prominent,  become  thrombosed. 
They  then  gi'adually  become  smaller,  until  at  the  end  of  about 
a  week  thev  appear  onlv  as  small  brownish  cords. 

It  is  worthy  of  note  that  Bcrard  states  that  elevation  of 
temperature  is  almost  always  ('' presque  constamment ")  present 
dui'ing  the  first  eight  or  ten  davs  after  exothvropexv.  He 
explains  this  as  "thvroid  fever"  due  to  absorption  of  secretion 
from  the  interior  of  the  gland. 

In  the  course  of  several  weeks  after  the  operation  the  exposed 
gland  gradually  shrinks  and  recedes  behind  the  skin.  The  latter 
encroaches  upon  the  surface  of  the  tumour,  which  becomes 
covered  with  a  decreasins;  area  of  g-ranulations,  and  finallv  bv  a 
scar.  With  regard  to  the  ultimate  appearance  of  the  cicati"ix, 
Berard  expresses  himself  as  follows :  "  ^^^lat  is  usually  foimd  at 
the  end  of  some  months  (after  exothyropexy)  is  a  decolorised 
disc,  the  dimensions  of  which  vary  from  those  of  a  two-franc 
piece  (liV  inch)  to  those  of  a  five-franc  piece  (li  inch),  very 
smooth  and  shiny  or  else  bossy,  and  which  is  adherent  to  the 
deeper  parts  of  the  neck,  fixing  them  to  the  skin.  Sometimes 
the  appearance  is  still  more  ugly ;  the  little  cysts  which  form 
during  the  shrinking  of  the  tumour  become  adherent  to  the 
skin  and  project  externally  like  true  grafts  of  thyroid  tissue, 
resembling  gi'apes  embedded  in  the  skin." 

Berard  gives  an  excellent  photograph  of  a  scar  produced  by 
an  exothvropexv.  It  is  certainly  more  ugly  than  any  scar  I 
have  ever  produced  bv  anv  extirpation  or  enucleation  operation. 

Complications  of  the  Operation. — With  regard  to  serious  haemor- 
rhage, Berard  is  of  opinion  that  with  ordinary  care  it  may  usually 
be  avoided,  except  in  the  case  of  very  vascular  goitres  and  of 
those  which  are  very  adherent  to  surrounding  parts.  He  lays 
down  a  rule  with  regard  to  haemorrhao'e  due  to  wound  of 
capsular  veins,   namely  that   the  lobe    that  bleeds    should   be 


248  THH    THYROID    (iLAND. 

immediatcJv  luxated  externally.  This  tends  to  obviate  dangerous 
bleeding  into  the  cellular  tissue  of  the  neck.  The  haemorrhage 
moreover  tends  to  stop  spontaneously  after  dislocation  has  been 
effected.  If  bleeding  still  continue,  it  can  more  easily  be  arrested 
by  pressure  or  ligature.  If  luxation  of  the  lobe  prove  to  be 
impossible,  the  bleeding  must  be  arrested  by  leaving  clamp  forceps 
applied  to  the  bleeding  points. 

Secondary  haemorrhage  appears  to  be  rare,  occurring  only  when 
the  wound  has  accidentally  become  infected. 

Painful  dysphagia  appears  to  be  common  during  the  first  two 
or  three  days  after  bhe  operation.  In  about  one-third  of  the 
cases  bronchitis  appears  to  be  troublesome. 

Complications  due  to  the  mechanical  disturbance  and  dis- 
placement of  the  trachea  appear  to  be  not  inicommon,  although 
as  a  rule  after  exothyropexy  the  dyspnoea  is  relieved.  In  some 
cases  of  exothyropexy  not  onlv  has  the  dyspnoea  not  been 
relieved  but  it  has  positively  been  aggravated.  This  will  readily 
be  believed  by  those  who,  like  mvself,  have  had  practical 
experience  of  the  injurious  effect  of  traction  upon  the  trachea  in 
the  course  of  an  ordinary  operation  of  extirpation.  If  the 
dyspnoea  be  aggravated  by  exothyropexy  it  is  recommended 
that  the  goitre  be  replaced,  the  surgeon  contenting  himself  with 
the  benefit  that  may  follow  mere  division  of  the  tissues  m  front 
of  the  goitre  ;  or  tracheotomy  may  become  necessary.  This  is, 
however,  always  a  very  serious  complication  of  any  operation 
upon  a  goitre,  owing  to  the  danger  of  setting  up  sepsis  in  the 
wounded  cellular  tissue  of  the  neck. 

In  at  least  one  case,  that  of  Jaboulay,  removal  of  the  manu- 
brium of  the  sternum  has  been  performed  to  obtain  access  to  a 
substernal  goitre  that  was  causing  severe  dyspnoea  and  that 
could  not  be  reached  by  any  other  means.  This  is  however  a 
very  serious  complication  and  one  that  can  be  very  rarely 
necessary. 

In  some  cases  in  which  exothyropexy  was  found  impracticable, 
owing  to  the  impossibility  of  effecting  the  dislocation,  the 
tumour  has  merely  been  laid  bare  by  the  operation.  The  wound 
has  been  packed  with  gauze.  Shrinking  of  the  goitre  may 
follow  this  simple  operation  just  as  it  may  after  a  simple 
division    of  the   isthmus.     The  possibility  however    of  serious 


•       EXOTHYROPEXY.  249 

increase  in  the  amount  of  dyspnoea  due  to  inflammatory 
swelling  must  be  borne  in  mind.  Infection  of  the  womid  is 
obviously  a  serious  danger  and  one  which  is  not  easy  to  avoid. 
Even  Bei^ard,  who  is  on  the  whole  a  warm  advocate  of  exothyro- 
pexy,  is  obliged  to  admit  that  "  it  is  very  difficult  to  keep  the 
dislocated  e-oitre  free  from  all  infection."  It  is  in  the  later 
stages  of  the  healing  process,  when  antiseptic  precautions  tend 
to  become  relaxed,  that  infection  is  apt  to  be  produced.  It  may 
be  followed  by  sloughing  of  the  exposed  gland  and  extension  of 
the  inflammatory  process  to  the  deeper  parts  of  the  neck  and 
chest. 

MortalHij  after  Eocotliyropexy. — It  is  difficult  to  j  udge  of  the 
true  mortality  after  this  operation.  Berard  has  collected  sixty- 
five  cases  of  exothyropexy  performed*  chiefly  upon  parenchy- 
matous goitre  but  also  upon  several  exophthalmic  goitres.  In 
four  of  these  cases  death  resulted  from  pneumonia,  septic 
infection  with  haemorrhage  and  acute  Graves's  disease  (two  cases) 
respectively. 

Among  the  sixty-one  ciases  that  recovered  were  cases  in  which 
sloughing  occurred,  in  which  tracheotomy  became  necessary,  or 
in  which  other  operations  such  as  extirpation  or  enucleation 
were  subsequently  performed.  Many  of  the  cases  appear  to 
have  beneflted  greatly  by  the  operation,  others  seem  to  have 
been  improved  but  little  if  at  all. 

*  By  Poncet  (15  cases),  Jaboiilay  (35),  Pollossou  (5),  Blauc  (3),  Guillemot  (3), 
Eocket,  Albei'tin,  Buchanan,  and  Hartmann  (1  each). 


CHAPTER   XVI. 

DIVISION  OR  RESECTION  OF  THE  THYROID  ISTHMUS. 

Early  cases — "Atrophy"  of  lateral  lobes — Explanation  of — Dyspnoea 
not  due  to  backward  pressure  of  isthmus — Results  of  the  operation — 
Reappearance  of  goitre — Conclusions. 

This  operation  is  performed  much  more  often  in  England  than 
in  other  countries,  and  has  been  more  highly  praised  by  English 
than  by  Continental  surgeons. 

Duncan  Gibb  appears  to  have  been  the  first  to  advocate  its 
performance.  In  the  Lancet  for  1875  he  published  two  cases 
in  which  Mr.  Holthouse,  of  the  Westminster  Hospital,  had  put 
into  practice  the  operation  suggested  to  him  by  his  medical 
colleague.  The  first  case  was  that  of  a  cook,  aged  29,  who  had 
had  a  goitre  for  about  two  years.  Both  lobes  and  the  isthmus 
were  affected.  The  amount  of  dyspnoea  does  not  seem  to  have 
been  great.  On  July  11,  1874,  Mr.  Holthouse  exposed  the 
thyroid  isthmus,  passed  a  ligature  round  each  end  of  it,  and 
removed  the  intervening  portion.  On  July  17  the  last  ligature 
came  away,  and  the  woman  subsequently  made  a  good  recovery. 
Four  months  later  she  was  in  oood  health :  the  goitre  was 
smaller  and  caused  no  trouble. 

The  second  case  was  that  of  a  girl,  aged  17,  who  had  had  a 
goitre  for  many  years.  The  whole  gland  was  enlarged,  and 
caused  dysphagia,  dyspnoea,  and  cough.  Some  severe  paroxysms 
of  dyspnoea  which  had  recently  occurred  made  surgical  inter- 
ference desirable.  On  December  15,  1874,  an  operation  some- 
what similar  to  the  last  was  performed  by  Mr.  Holthouse. 
Instead,  however,  of  dividing  with  the  knife  that  portion  of 
the  gland  that  lay  between  the  ligatures,  he  left  it  to  slough 
away.       After   the    operation    the   circumference    of   the   neck 


DIVISION    OR    RESECTION    OF   THE    ISTHMUS.     251 

diminished    from    14fh    to    13J    in.       The   patient    recovered, 
apparently  much  reheved. 

For  a  period  of  nearly  nine  years  the  operation  appears  to 
have  attracted  very  little  notice,  no  cases  having  been  published 
during  that  period.  About  the  year  1883  M.  Tillaux,  of  Paris, 
began  to  perform  the  operation,  and  soon  afterwards  Mr.  Sydney 
Jones  followed  him  and  published  some  cases.*  From  this  time 
onwards  the  operation  has  been  practised  extensively  in  this 
country. 

I  have  collected  twenty  cases  from  various  sources  published 
and  unpublished.  In  eight  at  least  of  these  the  goitre  diminished 
in  size  and  the  improvement  lasted  many  months,  in  several 
cases  more  than  a  year.  In  four  cases  death  occurred.  In  two 
at  least  of  the  cases  the  dyspnoea  had  been  very  severe  ;  in  one 
of  them  death  occurred  during  the  operation.  In  one  case  the 
operation  failed  to  relieve  the  dyspnoea,  and  removal  of  one  lobe 
had  to  be  performed. 

Mr.  Jones  has  pointed  out  that  the  operation  not  only  often 
gave  relief  from  the  dyspnoea,  but  that  it  caused  a  remarkable 
diminution  in  the  size  of  the  goitre,  or,  to  use  his  own  words, 
"  an  atrophy  of  the  lateral  lobes." 

That  both  these  results — namely,  relief  from  the  dyspnoea 
and  diminution  in  the  size  of  the  goitre,  at  any  rate  for  a  time 
—do  usually  follow  the  operation  there  can  be  no  doubt,  judging 
from  the  twenty  cases  before  mentioned. 

Two  questions  may  be  discussed  in  connection  with  this 
operation :  "  What  is  the  mode  in  which  the  relief  from  the 
dyspnoea  is  effected  ? ''  and  "  Is  the  diminution  in  the  size  of  the 
goitre,  and  with  it  the  relief  from  dyspnaea,  permanent.''" 

It  is  frequently  stated  that  as  the  isthmus  is  a  band  uniting 
the  two  lateral  lobes,  division  of  it  will  allow  these  lobes  to 
separate  from  each  other  and  so  relieve  the  dyspnoea.  This 
seems  at  first  sight  a  plausible  explanation,  but  it  is,  nevertheless, 
probably  not  usually  the  correct  one.  That  this  may  be  the 
result  of  the  operation  in  some  cases  is  not  improbable.  That 
it  is  so  in  all  or  nearly  all  cases  cannot  be  admitted.  I  have 
seen  the  operation  performed  many  times,  and  have  frequently 

*  Full  details  of  Mr.  Jones's  cases  will  be  found  in  the  Lancet.  1883,  ii.  900, 
and  1884,  ii.  367. 


252  THK    THYROID    GLAND. 

noticed  that  after  the  division  has  been  effected  the  cut  surfaces 
have  not  separated  from  each  other  at  all.  Sometimes,  not 
only  has  the  isthmus  been  divided  but  a  considerable  portion 
of  it  removed.  What  frequently  happens,  then,  is  that  the 
lateral  lobes,  far  from  receding,  actually  come  closer  together 
to  fill  up  the  place  of  that  portion  of  the  gland  that  has  been 
removed. 

Mr.  C.  A.  Morton,*  describing  a  case  in  which  he  operated 
for  severe  dyspnoea  caused  by  a  parenchymatous  goitre,  says 
that  "  after  excision  of  more  than  an  incb  of  the  median  part 
of  the  p-land  the  lateral  lobes  came  tooether  in  the  middle  line." 

Then  again,  the  relief  from  the  dyspnoea  frequently  does  not 
occur  immediately,  but  only  after  the  lapse  of  some  hours  or 
days.  In  several  of  the  cases  before  mentioned  no  relief  what- 
ever followed  the  operation.  Thus,  in  an  operation  that  I 
witnessed  at  Universitv  College  Hospital  some  years  ago  upon 
a  boy  with  a  large  parenchymatous  goitre  causing  considerable 
dyspnoea,  a  portion  of  the  isthmus  was  removed.  The  cut 
surfaces  on  either  side  immediately  came  into  contact,  and  the 
boy  died  of  dyspnoea  a  few  hours  later. 

But  relief  from  the  dyspnoea  should  occur  immediately  after 
division  if  the  constricting  isthmus  were  the  cause  of  the 
dyspnoea. 

Gibb,  in  his  remarks  upon  the  two  cases  published  by 
himself,  sa^s  that  his  object  was  "  to  divide  or  remove  that 
portion  of  the  goitre  which  was  in  relation  with  the  trachea 
itself,  namely,  the  isthmus,  before  it  had  commenced  to  encircle 
the  tube  or  had  become  too  firmly  adherent.''  Speaking  of  his 
first  case,  he  says  that  he  considered  that  "  the  cure  of  the 
attacks  of  dyspnoea  was  impossible  without  the  removal  of  that 
portion  of  the  tumour  over  the  windpipe." 

It  is  clear,  then,  that  he  had  fallen  into  the  rather  serious 
mistake  of  supposing  that  the  cause  of  the  dyspnoea  lay  in  the 
direct  pressure  of  the  isthmus  upon  the  front  of  the  trachea. 
Hence  that  division  or  removal  of  the  isthmus  relieves  the 
trachea  from  pressure. 

I  venture  to  think  that  this  view  is  wholly  untenable. 

,  *  "  The  Causation  and  Treatment  of  Sudden  Dyspncea  in  Goitre,"  Bristol 
Med.  Ch'w.  Jovr/i.,  1896,  p.  221. 


DIVISION    OR    RESECTION    OF    THE    ISTHMUS.     253 

The  pressure  of  the  goitre  upon  the  trachea  does  not  cause 
an  antero-posterior  but  a  lateral  flattening  of  the  trachea,  as 
may  be  seen  in  Fig.  2.  In  this  case  the  patient  died  from 
suffocation,  and  it  will  be  seen  that  the  trachea  is  greatlv 
flattened  laterally  like  the  scabbard  of  a  sword,  as  Denime  long 
ago  explained. 

The  trachea  is  never  flattened  antero-posteriorlv  bv  anv 
parenchymatous  goitre  or  by  any  other  form  of  general  and 
uniform  enlargement  of  the  gland.  AVhen  the  isthmus  alone 
is  involved  without  the  lateral  lobes,  as  bv  the  j^resence  of  a 
tumour  within  it,  there  mav  be  a  slight  amount  of  antero- 
posterior flattening;  but  such  goitres  never  cause  serious 
dyspnoea  unless  the  tumour  lies  actually  behind  the  sterniun, 
and  even  then  the  pressure  is  usuallv  oblique  rather  than 
antero-posterior. 

The  cause  of  the  dvspnoea  must  be  sought,  not  so  much  in  the 
condition  of  the  isthmus,  as  in  that  of  the  lateral  lobes  of  the 
goitre.  In  suffocating  parenchvmatous  goitre,  all  parts  of  the 
gland  are  swollen  and  exert  pressure  upon  everything  in  contact 
with  them.  That  is,  thev  exert  pressure  not  onlv  upon  the 
muscles  and  other  structures  outside  of  and  around  them,  but 
also  upon  the  trachea  which  lies  between  the  two  lateral  lobes. 
Hence,  it  happens  that  mere  division  of  the  isthmus  will  not  of 
itself  free  the  trachea  from  the  inward  pressure  of  the  lateral 
lobes. 

The  effect  of  removal  of  the  isthmus  mav  even  be,  as  in  the 
cases  mentioned  above,  to  cause  the  lateral  lobes  to  come  nearer 
to  each  other  and  so  to  increase  the  lateral  flattening  of  the 
trachea. 

The  real  cause  of  the  relief  from  the  dyspnoea  lies  chiefly  in 
the  shrinking  of  the  gland  which  follows  the  operation,  and  not 
in  the  mere  mechanical  separation  of  the  two  halves  of  the 
goitre. 

The  next  question  is,  "  How  is  this  shrinking  caused  1 "" 

We  must  bear  in  mind  that  the  enlargement  of  the  gland  in 
parenchvmatous  goitre  is  very  largely  due  to  over-distension  of 
the  vesicles  with  secretion  :  therefore  it  is  easy  to  miderstand 
that  removal  of  that  secretion  will  naturally  cause  diminution 
of  the  swelling.     This  is  shown  by  the  fact  that  the  diminution 


254  THE   THYROID    GLAND. 

does  not  occur  at  once  but  in  the  course  of  the  few  days  fol lowing 
the  operation.  During  this  time  the  viscid  colloid  secretion 
has  had  time  to  ooze  slowly  aw^ay  from  the  surface  of  the 
wound.  Indeed,  I  have  more  than  once,  after  operations  upon 
parenchymatous  goitre,  seen  this  colloid  secretion  coming  away 
from  the  gland.  Thus  in  one  case  there  formed  in  the  neck, 
under  the  recently  healed  skin  wound,  a  fluctuatino-  swelling 
which  was  at  first  thought  to  be  an  abscess,  but  which,  when 
opened,  was  found  to  contain  a  quantity  of  viscid  colloid  material 
that  had  evidently  drained  from  the  gland  into  the  wound. 
Notes  of  a  similar  occurence  will  be  found  in  a  good  many 
published  cases. 

Ao-ain,  the  more  fibrous  the  goitre  the  less  the  diminution  in 
size  that  will  take  place.  In  a  rare  case  of  truly  fibrous  goitre 
on  which  division  of  the  isthmus  was  performed  some  years  ago 
at  St.  Bartholomew's  Hospital  by  Sir  Thomas  Smith,  little  or 
no  diminution  in  size  followed  the  operation  and  the  dyspnaea 
was  not  relieved. 

Lastly,  as  the  wound  in  the  gland  heals,  and  the  further 
escape  of  colloid  material  is  thus  stopped,  the  goitre  often 
slowly  reappears,  if  the  conditions  which  originally  produced  it 
continue  to  act.  The  reappearance  of  the  goitre  is  doubtless 
due  to  reaccumulation  of  its  colloid  contents. 

The  following  case,  which  came  under  my  notice  in  St.  Bar- 
tholomew's Hospital  in  1886,  affords  a  good  illustration  of  this 
point.  The  patient  was  a  girl,  aged  17,  with  a  bilateral 
parenchymatous  goitre,  causing  such  extreme  dyspnoea  that  she 
was  almost  suffocated  by  it.  Division  of  the  isthmus  was 
performed  by  Mr.  Langton.  Not  the  least  relief  followed  and 
immediate  tracheotomy  became  necessary.  Within  a  week  from 
the  time  of  the  operation  the  goitre  had  shrunk  so  much  that 
scarcely  any  swelling  of  the  neck  was  noticeable.  Then  as  the 
wound  in  the  gland  healed,  the  goitre  gradually  re-enlarged 
mitil,  at  the  end  of  some  weeks,  it  had  neai'ly  regained  its  former 
size.  As  dyspnoea  was  found  to  occur  whenever  the  tracheotomy 
opening  was  closed,  it  became  necessary  to  do  some  further 
operation  and  the  right  half  of  the  gland  w-as  removed.  The 
same  sequence  of  events  now  occurred  in  the  remaining  half  of 
the  goitre.     At  first  it  gradually  diminished  in  size,  and  then,  as 


DIVISION    OR   RESECTION   OF   THE   ISTHMUS.     255 

the  wound  healed,  it  gradually  and  slowly  enlarged  again.  In 
most  of  my  own  cases  of  unilateral  extirpation  of  parenchy- 
matous goitre,  the  operation  has  been  followed  by  marked 
diminution  in  size,  and  then  by  re-enlargement,  of  the  remaining 
half  of  the  goitre. 

The  exact  manner  in  which  the  colloid  of  the  vesicles  passes 
from  them  to  the  cut  surface  of  the  gland  is  a  point  upon 
which  it  seems  unwise  to  express  a  definite  opinion.  There  is 
some  evidence  in  support  of  the  view  of  Boechat  and  others, 
that  all  the  thyroid  vesicles  communicate  with  each  other.  If 
this  be  so,  it  follows  that  any  incision  into  the  gland  will  tend 
to  drain  all  the  vesicles.  Possibly,  however,  the  drainage  is 
effected,  not  directly  but  indirectly,  through  the  medium  of  the 
lymphatics. 

All  these  facts  seem  to  point  to  the  following  conclusions : 

(i)  That  division  of  the  thyroid  isthmus  usually  relieves  dyspnoea, 
not  by  mechanically  allowing  the  two  halves  of  the  goitre  to 
separate,  but  by  draining  the  gland  of  its  colloid  secretion. 

(ii)  That  the  relief  aiForded  may  be  permanent,  but  that  fre- 
quently the  goitre  reappears  when  the  wound  has  healed  and 
the  secretion  is  again  pent  up  in  the  gland. 

(iii)  That  in  many  cases  in  which  very  urgent  dyspncea  is  pre- 
sent, a  mere  division  of  the  isthmus  will  not  relieve  the  dyspnoea 
sufficiently  quickly,  and  it  becomes  necessary  to  do  some  further 
operation,  either  tracheotomy  or,  better,  removal  of  some  con- 
siderable portion  of  the  goitre. 

The  operation  is  therefore  not  one  which  can  now  be  recom- 
mended, except  perhaps  in  certain  exceptional  cases.  For 
parenchymatous  goitre  without  dyspnoea  it  is  not  necessary, 
because  such  cases  are  better  treated  by  medical  means,  such  as 
the  administration  of  iodine  or  thyroid  extract.  Cases  of 
parenchymatous  goitre  in  which  dyspnoea  is  considerable  and 
which  do  not  yield  to  medical  measures  generally  require  re- 
moval of  a  considerable  portion  of  one  or  other  lateral  lobe.  The 
possible  danger  of  trusting  to  a  mere  division  of  the  isthmus 
has  already  been  mentioned.  When  the  dyspncea  is  very  severe 
and  urgent,  division  of  the  isthmus  cannot  be  relied  upon  to 
give  relief  sufficiently  quickly.  In  some  few  such  cases  how- 
ever, it  may  be  advisable  to  divide  the  isthmus  and  then  to 


256  THE   THYROID    GLAND. 

watch  carefully  the  effect  of  this  before  doing  tracheotomy. 
But  tracheotomy  is  scarcely  ever  desirable  for  parenchymatous 
goitre,  except  at  the  hands  of  those  who  do  not  feel  able  to 
perform  the  larger  but  nuich  safer  operation  of  aseptic  uni- 
lateral extirpation. 

The  dangers  of  an  open  wound  such  as  that  produced  by 
division  of  the  isthmus,  or  of  the  necessary  septic  \\  ound  of  a 
tracheotomy,  are  obviously  greater  than  those  of  a  properly 
performed  aseptic  extirpation  of  one  lobe. 

An  extensive  resection  of  the  isthmus  may  sometimes  be 
preferable  to  unilateral  extirpation,  in  some  cases  of  parenchy- 
matous goitre  in  which  the  goitre  is  unusually  prominent  in 
the  middle  line.  Such  an  operation  is  however  usually  more 
severe  than  a  simple  unilateral  extirpation. 

For  all  cases  of  adenoma  or  cyst,  division  or  resection  of  the 
isthmus  is  unsuitable,  being;  far  inferior  to  enucleation. 


CHAPTER   XVII. 

TREATMENT  BY  EXTIRPATION  (THYROIDECTOMY). 

Difference  between  extirpation  and  enucleation — Partial  extirpation — 
Preparation  of  patient — Question  of  general  aufesthetic — Local  anajs- 
thetic — Position  of  patient — Skin  incision  :  oblique,  vertical,  transverse 
— Treatment  of  infi-a-hyoid  muscles — Recognition  of  gland — Isolation 
of  lobe — Ligature  of  thyroid  vessels — Veins  often  thin  and  liable  to 
tear — Treatment  of  inferior  thyroid  artery — Avoidance  of  recixrrent 
nerve — Treatment  of  isthmus — Arrest  of  haemorrhage — Cleansing  of 
wound — Asepsis  better  than  antisepsis — Suture  of  muscles,  of  skin — 
Question  of  drainage — Dressings — Use  of  sponge — Fixation  of  head 
and  neck — Position  of  patient  after  operation — After-treatment — 
Convalescence. 

The  removal  of  a  goitre  by  a  surgical  operation  may  be 
performed  by  one  or  other  of  two  widely  different  methods. 
These  two  operations  are  known  by  the  names  of  extirpation 
and  enucleation  and  it  is  highly  important  that  the  difference 
between  them  should  be  clearly  borne  in  mind. 

By  extirpation  is  meant  the  removal  of  the  gland  or  some 
part  of  it  (generally  one  half)  by  an  operation  conducted  as  far 
as  possible  outside  the  capsule.  The  principal  vessels  are  all 
tied  or  clamped  before  they  are  cut.  The  operation  is  performed 
deliberately,  step  by  step,  by  careful  dissection.  The  wound 
being  kept  free  from  blood,  the  operator  is  enabled  to  see 
exactly  what  he  is  doing.  He  thus  avoids  wounding,  on  the 
one  hand  the  plexus  of  veins  which  lie  on  the  surface  of  the 
gland  beneath  its  delicate  investing  capsule,  on  the  other  hand 
the  important  anatomical  structures  which  lie  in  close  proximity 
to  the  gland. 

Enucleation,  on  the  other  hand,  consists  in  the  shelling 
out  of  a  tumour  from  the  interior  of  the  gland.  The  removal 
of  the  tumour  is   usually  effected  rapidly  and  no  attempt  is 


258  THE   THYROID   GLAND. 

made  to  tie  the  vessels  until  after  the  tumour  has  been 
removed. 

The  difference  between  the  two  operations  is  analogous  to  the 
difference  between  the  removal  of  a  breast  as  performed  for 
carcinoma  and  the  removal  of  a  flbro-adenoma  from  that  organ  ; 
or  to  the  difference  between  a  hysterectomy  and  the  enucleation 
of  a  fibro-myoma  from  the  uterus. 

Each  of  these  operations  has  several  modifications  which  will 
be  described  later. 

Total  Extirpation. — This  operation  is  one  which  is  not 
now  to  be  recommended  on  account  of  the  grave  after-results 
which  are  known  to  follow  if  the  patient  be  deprived  of  the 
whole  thyroid  gland.  Moreover  it  is  in  my  opinion  never 
necessary,  except  possibly  in  some  very  exceptional  cases  of 
malignant  disease  involving  both  sides  of  the  gland. 

The  performance  of  total  extirpation  differs  in  no  Avay  from 
partial  extirpation,  except  that  both  halves  of  the  gland  are 
removed. 

Partial  Extirpation. — In  the  great  majority  of  cases 
extirpation  is  performed  upon  one  lateral  lobe  and  it  is  this 
operation  therefore  that  will  be  described  in  detail.  In  some 
cases  extirpation  of  one  lobe  is  followed  by  extirpation  of  a 
portion  of  the  opposite  lobe. 

The  preliminary  preparation  of  the  patient  includes  the 
administration  of  a  purgative  on  the  day  before  the  operation  and 
the  preparation  of  the  skin  of  the  neck.  The  skin  of  the  whole 
of  the  front  and  sides  of  the  neck  must  be  thoroughly  scrubbed 
with  hot  water  and  soap,  and  then  washed  with  spirit,  ether  or 
turpentine  to  remove  all  greasy  matter.  An  antiseptic  dressing 
of  carbolic  acid  lotion  1  in  30,  or  perchloride  of  mercury  1  in 
2000  is  then  applied  for  several  hours  before  the  operation  and 
is  to  be  removed  only  when  the  operation  is  about  to  be 
commenced. 

Anaesthetic. — The  question  of  the  administration  of  an 
anaesthetic  is  an  important  one.  If  the  patient  has  little  or  no 
dyspnoea  or  stridor,  and  if  there  is  no  history  of  paroxysms  of 
dyspnoea,  then  there  can  be  no  objection  to  the  administration  of 
a  general  anaesthetic. 

But  if,  on  the  other  hand,  there  seems  to  be  any  probability 


TREATMENT   BY   EXTIRPATION.  259 

that    serious    dyspnoea    may    occur    during   the    course    of  the 
operation,  then  it  is  certainly  better  to  dispense  altogether  with 
a  general  anaesthetic  and  to  do  the  operation  under  cocaine  or 
eucaine.     In  cases  where  severe  dyspnoea  is  actually  present  at 
the  time  of  operation  the  use  of  a  general  ana?sthetic  involves 
much  danger.     Many  cases  have  been  recorded  in  which  sudden 
death  from  the  anaesthetic  has  occurred  in  the  course  of  the 
operation  or  even   before   the    operation   has    actually   begun. 
With  the  help  of  cocaine  or  eucaine  the  removal  of  a  goitre 
may  be  effected  with  very  little  pain.     Patients   upon  whom 
I  have  operated  without  the  use    of  general  anaesthesia  have, 
after  the  operation,  always  assured    me    that   the   amount    of 
pain  felt  by  them  was  really  quite  trivial.     Directly  the  tumour 
has  been  removed,  and  the  danger  of  suffbcation  is  over,  an 
anaesthetic  may  be  given,  if  it  be  thought  desirable,  while  the 
wound  is  being  sewn  up.     I  have  been  in  the  habit  of  offering 
an  anaesthetic  to  the  patient  at  this  stage,  but  up  to  the  present 
time  in  no  case  has  the  offer  been  accepted,  the  patient  always 
saying  that  the  pain  was  not  sufficiently  great  to  deinand  it. 
Even  if  no  anaesthetic  of  any  kind,  either  local  or  general,  be 
used,  the  pain  of  an  operation  for  goitre  is  confined  chiefly  to 
the  beginning  and  the  end  of  the  operation,  when  the  skin  is 
being  incised  or  sewn  up.     The  patients  often  complain   also 
when  traction  is  exerted  upon  the  tumour  or  upon  the  deeper 
parts  of  the  wound.     In  cases  of  severe  dyspnoea  there  is  a  great 
advantage  in  the  patient  being  conscious,  since   he  can  then 
immediately  give  warning  if  the   operator  be  pressing  unduly 
upon  the  narrow  trachea.     Patients  suffering  from  suff'ocative 
goitre  have  on  several  occasions  informed  me  that  they  dreaded 
the  taking  of  an  anaesthetic  more  than  the  actual  operation  and 
have  felt  relieved  at  being  informed  that  the  administration  was 
neither  necessary  nor  desirable.     At  the  same  time  probably 
few  patients  will  go  so  far  as  to  declare,  as   one  of  Kocher's 
patients  did,  that  it  was  a  real  pleasure  to  be  operated  upon  ! 
By  this  he  meant  no  doubt  that  the  relief  produced  by  the 
removal  of  a  suffocating  goitre  was  so  great  that  the  discomfort 
of  the  operation  was  as  nothing  to  him. 

A  minor  advantage  in  dispensing  with  the  use  of  an  anaesthetic 
is  that  the  patient  is  saved  much  of  the  retching  and  vomiting 


260  THE   THYROID   GLAND. 

ihat  fre(juently  follow  a  prolonged  operation  performed  under 
general  ana?.sthesia.  The  rapid  healing  of  the  wound  is  thereby 
facilitated. 

If  a  general  anaesthetic  be  employed  it  is  well  to  give  as  small 
a  quantity  of  it  as  possible,  and  to  keep  the  patient  only  lightly 
under  its  influence. 

If  cocaine  be  used,  a  solution  containing  not  more  than  half  a 
grain  should  be  injected  in  several  places  in  the  line  of  the 
proposed  incision.  The  use  of  cocaine  in  larger  doses  is  apt  to 
be  followed  by  faintness  or  even  by  more  dangerous  symptoms. 
Eucaine  may  be  used  in  much  larger  doses  and  has  further  the 
advantage  that  it  can  be  sterilised  by  boiling.  Both  solutions 
decompose  easily  and  should  therefore  be  freshly  prepared 
shortly  before  use.  An  injection  of  a  quarter  or  a  third  of  a 
grain  of  morphia  about  twenty  minutes  before  the  commencement 
of  the  operation  is  a  useful  adjunct  to  the  use  of  the  local 
anaesthetic. 

Position  of  the  Patient. — Some  surgeons  prefer  to  have 
the  patient  in  a  half-sitting  position.  For  myself,  I  prefer  that  he 
should  be  in  the  recumbent  position,  but  with  the  shoulders  well 
raised.  The  head  should  be  extended  as  far  as  is  compatible 
with  safety,  so  as  to  draw  the  goitre  as  much  as  possible  away 
from  the  thorax.  Much  extension  of  the  head,  however,  may 
interfere  seriously  with  the  patient's  respiration.  It  is  well  to 
ascertain,  before  the  operation  is  begun,  in  what  position  the 
patient  can  breathe  most  comfortably,  and  then  to  get  an 
assistant  to  hold  the  head  firmly  in  that  position  throughout 
the  operation.  By  these  means  the  trachea,  often  greatly 
narrowed,  is  less  likely  to  become  kinked  and  occluded. 

Skin  Incision. — Many  different  skin  incisions  have  been 
practised.  The  choice  depends  largely  upon  the  size  and  shape 
of  the  goitre. 

There  are  three  chief  varieties  :  (1)  The  oblique  incision  in  the 
long  axis  of  the  tumour  that  is  to  be  removed ;  generally  along 
the  inner  border  of  the  sterno-mastoid  muscle.  This  is  the 
incision  that  should  be  adopted  in  most  cases  of  extirpation  and 
in  those  generally  in  which  the  operation  is  likely  to  be  difficult 
or  dangerous.  It  gives  the  operator  plenty  of  room,  and 
enables  him  to  reach  the  upper  horn  of  the  gland  without  undue 


TREATMENT   I3Y    EXTIRPATION. 


2{)1 


262  THE    THYROID   GLAND. 

difficulty.  The  lower  end  of  the  incision  should,  in  almost  all 
cases,  be  carried  down  to  the  upper  border  of  the  sternum.  If 
it  be  intended  to  operate  upon  both  lobes  of  the  thyroid,  the 
incision  should  be  made  in  a  more  slanting  direction,  the  lower 
part  of  the  incision  being  carried  well  across  the  middle  line  at 
a  somewhat  higher  level  than  the  top  of  the  sternum.  In  some 
cases  of  bilateral  extirpation  the  angular  or  Y-shaped  incision, 
with  the  point  of  the  angle  opposite  the  cricoid  cartilage,  origin- 
ally recommended  by  Kocher,  may  be  employed,  but  is  seldom 
necessary.  I  have  never  yet  found  any  difficulty  in  getting  easy 
access  to  both  lobes  through  a  single  incision,  and  have  rarely 
employed  the  angular  incision. 

Occasionally,  when  the  tumour  is  very  large,  it  is  desirable  to 
make  an  elliptical  incision,  so  as  to  remove  a  large  portion  of 
skin.  Thus  in  the  patient  from  whom  I  removed  the  large  goitre 
shown  in  Figs.  34-37  (pp.  78-80),  an  oblique  incision  was  made 
across  the  front  of  the  tumour  and  a  second  curved  one  along 
the  right  and  lower  borders.  As  a  rule,  however,  no  excision  of 
skin  is  required,  even  in  removing  goitres  of  considerable  size. 
The  redundant  skin  soon  contracts.    {See  Figs.  87, 103,  and  111.) 

(2)  The  vei'tical  incision  may  be  used  for  goitres  situated  in  or 
near  the  middle  line  of  the  neck,  especially  if  they  be  small.  It 
involves  less  interference  with  the  infra-hyoid  muscles,  but,  on 
the  other  hand,  renders  access  to  the  region  of  the  superior 
thyroid  artery  less  easy.  In  some  cases  of  deep-seated  tumour 
beliind  the  sternum  in  which  the  operator  is  uncertain  which 
half  of  the  gland  should  be  removed,  the  vertical  incision  may 
be  employed  for  exploratory  purposes,  the  incision  being  sub- 
sequently prolonged  obliquely  upwards  to  the  right  or  left,  as 
desired. 

It  has  the  disadvantage  that  in  young  people  the  resulting 
scar  is  apt  to  become  contracted  and  ugly. 

(3)  The  transverse  incision  a  little  above  the  upper  border  of 
the  sternum  gives  the  best  results  as  regards  the  scar,  but,  on  the 
other  hand,  it  does  not  give  the  operator  nearly  so  much  room. 
It  is  consequently  less  easy  to  reach  the  upper  horn  of  the  gland 
unless  the  goitre  is  large  and  prominent.  To  obtain  sufficient 
room,  it  is  often  necessary  to  divide  very  freely  the  infra-hyoid 
and  even  the  sterno-mastoid  huuscles.     It   is   most  suitable  for 


TREATMENT   BY   EXTIRPATION. 


263 


CO       X 


g  g 


r 


264  THE   THYROID    GLAND. 

prominent  goitres,  for  small  goitres  low  down  in  the  neck,  and 
for  easy  cases  of  enucleation  in  general.  It  is,  in  my  opinion, 
not  to  be  recommended,  as  a  rule,  to  those  operators  who  have 
had  but  little  experience  in  removing  goitres. 

If  care  be  taken  to  place  the  incision  in  the  line  of  one  of  the 
natural  creases  of  the  skin,  the  subsequent  scar  will  be  scarcely 
visible,  and  can,  moreover,  be  easily  concealed  by  the  dress.  In 
the  case  of  ladies  wlio  wish  to  \\'ear  low  dresses  the  scar  can  be 
easilv  hidden  by  a  necklace  or  a  band  of  velvet. 

After  division  of  the  j3latysma_and  fascia,  the  superficial 
veins  of  the  neck  are  exposed,  and  several  of  them  will  probably 
rcc[uire  ligature.  The  oblique  anterior^jugular  vein  will  generally 
he  found  running  along  the  inner  border  of  the  sterno-mastoid, 
and  should  be  tied.  Care  should  be  taken  in  making  the  oblique 
skin  incision  not  to  split  open  this  vein.  At  the  lower  end  of 
the  incision,  just  above  the  sternum,  a  transverse  vein  will 
generallv  be  found,  requiring  a  double  ligature. 

The  infra-hyoid  musclgs  must  now  be  dealt  with.  In  the 
case  of  small  goitres  near  the  middle  line,  it  may  be  possible  to 
draw  these  muscles  aside  without  dividing  them.  Care  should  be 
taken,  whenever  possible,  to  draw  them  outwards,  not  inwards, 
in  order  to  avoid  dividing  the  nerves  Avhich  enter  their  outer 
borders.  If  these  nerves  be  divided  the  muscles  atrophy,  and 
afterwards  cause  an  unsightly  hollow  in  the  neck.  For  the 
same  reason,  if  the  muscles  have  to  be  divided,  as  is  usually  the 
case,  they  should  be  cut  near  their  upper  ends,  close  to  the  hyoid 
bone,  and  then  thrown  dowuAvards  and  outwards.  At  the  end 
of  the  operation  they  can  then  be  replaced  and  sutured  without 
nmch  harm  having  been  done  to  them.  If  the  operation  is 
likely  to  be  a  difficult  or  dangerous  one,  it  is  not  worth  while  to 
spend  time  over  a  comparatively  unimportant  point  like  this  ; 
in  such  cases  the  muscles  may  be  divided  wherever  it  seems  most 
convenient  to  do  so.  When  the  transverse  incision  is  used,  the 
skin  should  be  drawn  upwards  (or  downwards)  before  the 
muscles  are  divided,  so  that  the  wounds  in  the  skin  and  muscles 
do  not  correspond.  Otherwise  the  muscles  are  likely  to  adhere 
to  the  cicatrix  and  cause  a  certain  amount  of  deformity. 

The  infrahyoid  muscles  are  often  very  much  thinned  and 
spread  out  over  the  surface  of  the  goitre.    I  have  even  seen  them 


TREATMENT   BY   EXTIRPATION. 


260 


r—    a 


O  - 

ti  = 

(D  = 

r— I  - 


r 


CL 


266  THE   THYROID    GLAND. 

mistaken  by  an  inexperienced  operator  for  the  proper  capsule 

~of"the   goitre.     Sometimes    they  lie   in    deep    grooves   on   the 

surface  of  the  gland,  and  must  be  carefully  lifted  out  of  these 

The  surface  of  the  thyroid  gland  has  now  been  laid  bare.  It 
is  covered  by  a  layer  of  loose  connective  tissue  lying  immedi- 
ately  outside  the    capsule   of   the  _  gland.     This    layer  is  very 


yW 


Fig.  93. — The  preceding-  (Fig-.  91),  three  weeks  after  operaJou. 
Showing-  small  transverse  scar  low  down  in  the  neck.  {See 
Appendix,  Case  53,  p.  346.) 

distinct  and  easily  recognised  in  all  cases  except  those  in  which 
previous  inflammation  has  matted  the  parts  together.'  Thjs  is 
likely  to  be  the  case  when  the  goitre  has  been  subjected  to 
i'AkJ    injection,  or  if  suppuration  hes  taken  place  in  it. 

The  capsule  of  the  gland  can  usually  be  recognised  without 
difficulty^by  the  network  of  large  veins  that  ramify  beneath  it.  _ 

The  gland  together  with  its  capsule  has  now  to  be  separated 
from  the  surrounding  parts,  f.nd  m  perfoiming  this  part  of  the 


TREATMENT    BY   EXTIRPATION.  267 

operation  the  greatest  care  must  be  exercised  not  to  wound,  on 
the  one  hand  the  plexus  of  the  vein  Iving  beneath  the  capsule, 
on  the  other  hand  the  important  structures  lying  in  close  contact 
with  the  gland. 

If  the  capsule  and  its  veins  be  wounded  the  haemorrhage 
may  be  very  difficult  to  control.  If  forceps  be  applied,  the 
vessels  or  the  glandular  tissue  are  very  apt  to  tear,  and  further 
haemorrhage  takes  place.  Often  the  wounded  gland  oozes  blood 
in  an  alarming  and  uncontrollable  manner,  the  wound  is  obscured 
with  blood  and  the  subsequent  steps  of  the  operation  become 
much  more  difficult.  Even  roncfh  handlino;  of  the  o-land  mav 
lead  to  tearing  of  its  thinned  and  dilated  veins.  The  greatest 
care  should  therefore  be  taken  to  conduct  the  dissection  with  the 
utmost  carefulness  and  delicacy.  Should  a  vein  be  wounded 
accidentally,  it  may  be  possible  to  stop  the  hgemorrhage  by 
means  of  a  ligature  carefully  applied.  But  in  cases  in  which  a 
small  puncture  only  has  been  made  it  is  often  better  to  get  an 
assistant  to  put  one  finger  on  the  bleeding  point  and  to  continue 
the  dissection. 

The  front  of  the  gland  is  easily  cleared  and  the  muscles 
being  held  on  one  side  bv  retractors,  search  is  made  for  the 
pi'incipal  vessels,  which  must  be  tied  just  outside  the  points 
at  which  they  penetrate  the  capsule. 

It  is  generallv  best  to  begin  bv  clearing  the  upper  horn  and 
placing  ligatures  upon  the  superior  thyroid  artery  and  vein.  But 
if  severe  and  dangerous  dvspnoea  be  present  it  mav  be  best  to 
besin  bv  diseno-asins:  the  lower  horn,  so  as  to  relieve  the  trachea 
from  pressure.  If  the  vessels  are  small  thev  mav  be  tied  in  a 
common  ligature,  but  if  thev  are  large  they  should  be  tied 
separatelv.  It  is  often  best  to  tie  the  arterv  before  the  vein,  so 
as  to  diminish  the  amount  of  blood  in  the  gland. 

The  artery  will  generallv  be  found  without  much  difficulty  at 
the  inner  border  of  the  apex  of  the  upper  horn.  It  is  desirable 
to  tie  it  rather  high  so  that  the  ligature  may  be  above  the 
origin  of  a  large  branch  which  is  frequently  found  running  from 
near  the  apex  down  the  back  of  the  gland. 

Sometimes  when  the  g-oitre  is  large  and  extends  nearlv  to  the 
lower  jaw,  there  is  considerable  difficulty  in  obtaining  access  to 
the  arterv,  which  lies  at  the  bottom  of  a  narrow  space  between 


268  THE   THYROID    GLAND. 

the  tumour  and  the  jaw.  This  difficulty  is  increased  if  the 
head,  on  account  of  tlie  dyspnoea,  cannot  be  thrown  well  back- 
wards. 

Both  veins  and  arteries  are  secured  with  double  ligatures  and 
the  vessels  then  divided. 

The  superior  thyroid  artery  and  vein  having  been  secured, 
attention  is  next  directed  to  the  middle  and  accessory  thyroid 
veins.  The  most  common  situation  of  these  veins  is  shown  in 
Fig.  7.  They  should  be  carefully  isolated  and  tied  with  double 
ligatures  before  being  divided ;  they  should  be  tied  just  where 
they  leave  the  capsule  of  the  gland. 

In  dissecting  towards  the  outer  border  of  the  goitre,  care 
should  be  taken  to  avoid  wounding  the  internal  jugular  vein, 
which  is  frequently  expanded  over  the  side  of  the  tumour  and 
may  easily  be  wounded.  It  frequently  lies  in  front  of  or  even 
internal  to  the  carotid  artery  and  the  pulsation  of  this  vessel  is 
consequently  not  a  safe  guide  to  the  position  of  the  vein. 

The  branches  of  the  inferior  thyroid  veins  running  downwards 
from  the  lower  part  of  the  goitre  must  now  be  dealt  with  in  a 
similar  manner.  Here,  again,  there  may  be  much  difficulty  in 
obtaining  access  to  the  veins  if  the  goitre  be  a  large  one  and 
extend  down  behind  the  sternum.  The  importance  of  raising 
the  goitre  so  as  to  obtain  as  much  room  as  possible  is  obvious. 
Care  should  be  taken  not  to  cut  or  tear  any  of  these  veins  before 
they  are  tied,  lest  they  should  retract  into  the  cellular  tissue 
behind  the  sternum  and  there  give  rise  to  troublesome  haemor- 
rhage. 

The  goitre  having  been  completely  freed  from  its  vascular 
connections  above,  below,  and  on  the  outer  side,  should  now,  if 
possible,  be  lifted  up  out  of  its  bed  and  turned  over  towards  the 
opposite  side,*  in  order  that  the  inferior  thyroid  artery  and 
accompanying  veins  may  be  dealt  with. 

If  the  fixity  of  the  tumour  be  such  that  the  latter  cannot  be 
lifted  out  of  its  bed,  then  the  difficulty  of  tying  the  artery  is 

*  lu  some  cases,  mid  especially  when  the  goitre  is  a  pi-oiiiineiit  one,  tliis 
dislocation  of  the  tumour  out  of  the  wound  may  be  effected  with  advantage  at  a 
much  earlier  stage  of  the  operation,  before  the  superior  thyroid  vessels  and 
inferior  thyroid  veins  have  been  tied.  In  these  cases  the  lateral  thyroid  veins 
must  be  tied  before  the  dislocation  is  effected.  The  early  dislocation  of  the 
tumour  has  the  adA'antage  of  affording  relief  to  the  pressure  on  the  trachea. 


TREATMENT   BY   EXTIRPATION.  269 

much  increased.  Access  to  the  artery  is  favoured  ibv  drawino- 
the  sterno-mastoid  muscle  well  outwards,  or  even  by  dividino- 
some  of  its  fibres.  Or  it  may  be  advisable  to  postpone  ligature 
of  the  artery  until  the  isthmus  has  been  cut  through,  and  the 
tumour  thus  rendered  more  movable. 

The  inferior  thyroid  artery  may  be  tied  in  one  or  other  of 
two  situations.  The  main  trunk  may  be  tied  at  the  inner 
border  of  the  scalenus  anticus  muscle,  just  at  the  point  where 
it  changes  its  direction  from  vertical  to  horizontal,  curving 
inwards  to  enter  the  gland.  Or  the  branches  may  be  tied  close 
to  the  gland  itself. 

If  the  main  artery  be  tied,  care  must  be  taken  not  to  wound 
the  sympathetic  nerve  which  lies  in  very  close  relation  to  it. 
It  is  quite  possible  also  to  mistake  the  vertebral  for  the  thyroid 
artery. 

The  branches  of  the  artery  are  more  easily  found,  and  should 
be  tied  inside  the  line  of  the  recurrent  laryngeal  nerve.  Which- 
ever method  be  adopted,  the  position  of  this  nerve  should  be 
constantly  be  borne  in  mind  lest  it  be  accidentally  cut  or 
included  in  a  ligature.  It  lies,  most  commonly,  superficial  to 
the  artery,  but  may  pass  behind  it.  It  may  lie  among  the 
branches,  some  of  these  passing  in  front  of  and  others  behind 
the  nerve. 

Some  operators  recommend  that  search  be  made  for  the 
nerve  and  that  it  be  dissected  out  and  held  on  one  side.  If 
the  operator  is  doubtful  about  the  position  of  the  nerve,  he 
may  do  well  to  follow  this  advice.  It  is  better,  however,  to 
know  exactly  where  the  nerve  should  be  and  to  avoid  it  without 
unduly  exposing  it.  The  wound  must  be  kept  as  free  as  possible 
from  blood  while  this  stage  of  the  dissection  is  being  carried 
out. 

In  removing  the  posterior  border  of  the  gland  from  the 
pharynx  and  other  structures  on  its  inner  side,  the  anatomical 
arrangement  of  the  fascia  at  the  back  of  the  gland  (described 
on  p.  7)  must  not  be  forgotten.  In  those  cases  especially 
in  which  the  goitre  sends  a  prolongation  inwards  behind  the 
pharynx  and  oesophagus,  the  arrangement  of  the  fascia  is  liable 
to  deceive  the  operator,  and  to  carry  him,  in  his  dissection,  away 
from  the  surface  of  the  gland.     It  is  probably  a  want  of  due 


270  THE   THYROID   (JLAND. 

appreciation  of  this  important  anatomical  point  that  has  led  in 
some  recorded  cases  to  an  unexpected  wound  of  the  pharynx  or 
trachea. 

The  next  step  in  the  operation  is  the  division  of  the  isthmus. 
The  principal  vessels  lie  along-  its  upper  and  lower  borders  and 
should  be  secured  in  these  situations  with  double  ligatures. 
Any  veins  visible  upon  the  anterior  surface  may  be  clamped. 
The  isthmus  is  then  freely  divided  with  knife  or  scissors.  The 
few  vessels  that  bleed  from  the  cut  surface  of  the  isthmus  must 
be  picked  up  with  forceps  and  tied.  If  the  isthmus  is  small,  it 
may  be  included  in  a  single  ligature,  which  is  drawn  tight  as 
the  glandular  tissue  is  divided.  This  proceeding  tends  to 
prevent  the  escape  of  colloid  into  the  wound.  If  the  isthmus 
is  very  thick  it  may  mechanically  prevent  the  goitre  from  being 
turned  over  in  the  manner  previously  described. 

In  such  a  case  it  may  be  impossible  to  reach  the  inferior 
thyroid  artery  satisfactorily,  and  the  isthmus  must  then  be 
divided  at  an  earlier  stage  of  the  operation  before  search  is 
made  for  the  artery. 

I  have  never  found  the  haemorrhage  from  the  substance  of  the 
isthmus  to  be  serious.  The  principal  vessels  lie  upon  the  surface 
immediately  beneath  the  capsule. 

After  the  isthmus  has  been  divided,  the  few  remaining 
connections  of  the  tumour  may  be  severed  and  the  tumour 
removed. 

In  dividing  the  band  of  connective  tissue  that  unites  the  gland 
to  the  cricoid  cartilage,  care  must  again  be  taken  to  avoid 
Avounding  the  recurrent  nerve  which  lies  in  close  proximity. 

Indeed,  at  this,  the  final  stage  in  the  removal  of  the  tumour, 
it  is  frequently  a  good  plan  to  carry  the  knife  a  little  outwards 
into  the  gland  itself.  By  thus  making  the  section  a  little 
outside  the  nerve  and  leaving  a  small  portion  of  the  gland 
and  its  capsule  to  protect  it,  the  risk  of  wounding  the  nerve  is 
still  further  obviated. 

The  goitre  having  been  removed,  the  treatment  of  the  ex- 
tensive wound  of  the  neck  next  demands  attention. 

All  haemorrhage  must  be  scrupulously  arrested.  It  is  espe- 
cially on  the  inner  surface  of  the  wound  that  several  small  bleeding 
points  may  be  found  to  require  ligature. 


TREATMENT   BY   EXTIRPATION.  271 

Any  bits  of  blood-clot  that  may  remain  in  the  wound  must 
be  carefully  removed  by  sponging. 

If  perfect  asepsis  has  been  maintained  throughout  the  opera- 
tion, as  it  should  have  been,  the  wound  requires  no  further 
cleansing  than  is  afforded  by  gentle  sponging  with  sterile  saline 
solution,  or  by  laying  against  it  a  sponge  that  has  been  wrung 
out  of  weak  sublimate  solution.  Irrigation  of  the  wound  with 
strong  solutions  of  carbolic  acid  or  perchloride  of  mercury  should 
be  avoided  as  being  unnecessary  and  harmful.  It  is  aseptic 
rather  than  antiseptic  treatment  that  is  desired  in  the  removal 
of  a  goitre. 

In  order  to  preserve  asepsis  during  the  course  of  the  operation 
it  is  desirable  that  as  little  as  possible  of  the  wound  should  be 
exposed  at  any  one  time.  While  the  operator  is  working  at  any 
one  part  of  it  his  assistant  should  take  care  to  cover  the  rest 
of  it  with  layers  of  sterilised  gauze.  This  not  only  keeps  the 
wound  clean  but  also  checks  haemorrhage  from  minute  vessels. 

The  dangers  of  sepsis  in  an  extensive  wound  involving  the 
cellular  tissue  of  the  neck  are  too  well  known  to  require  further 
mention. 

If  the  infra-hyoid  muscles  have  been  divided,  the  cut  ends 
are  replaced  and  accurately  united  by  fine  buried  sutures.  A 
few  points  of  suture  may  also  be  used  to  unite  the  cut  edges  of 
the  platysma. 

It  is  generally  advisable  to  drain  the  wound  for  twenty-four 
hours.  This  is  best  effected  by  laying  in  it  a  sterilised  strip  of 
gutta-percha  tissue  or  gauze,  or  a  drainage-tube. 

In  cases  in  which  the  asepticity  of  the  wound  is  doubtful,  as 
in  some  cases  of  suppurating  goitre,  the  safest  course  to  pursue 
is  to  pack  the  whole  wound  with  strips  of  gauze.  For  such 
cases  it  has  been  recommended  to  cover  the  whole  internal 
surface  of  the  wound  with  a  layer  of  iodoform  gauze  and  then 
to  place  inside  this,  strips  of  gauze  wrung  out  of  some  antiseptic 
solution.  The  latter  must  be  changed  daily,  but  the  former 
may  be  left  in  for  many  days  until  it  becomes  loose  and  can  be 
removed  without  difficulty. 

The  edges  of  the  skin  wound  must  be  accurately  united  by 
fine  sutures  of  silk  or  fishing  gut. 

The  wound  is  then  covered  with  strips  of  antiseptic  gauze 


272  THE    THYROID    (iLAND. 

wrung  out  as  dry  as  possible.  Follow  ing-  the  practice  of  Jiflliaiid 
and  others,  I  usually  place  outside  the  first  layer  of  gauze  one 
or  more  marine  sponges  at  the  sides  of  the  neck.  These  tend 
to  keep  the  surfaces  of  the  woiuid  in  contact  and  also  help  to 
keep  the  trachea  in  place. 

Outside  the  S'auze  dressing  a  thick  layer  of  cotton-wool  must 


Fig.  94. — Bilateral  Parenchymatous  G-oitre.    The  riyi't  lobf 

was  C'xtirpatLMl  on  account  of  dyspna'ii. 

be  placed.  This  should  cover  a  large  area,  from  the  chin  to  the 
lower  part  of  the  sternum,  and  laterally  as  far  as  the  shoulder  on 
eithfer  side. 

It  is  important  that  the  bandages  should  be  applied  so  as 
to  lix  the  head,  neck,  and  shoulders,  and  thus  keep  the  wound 
as  quiet  as  possible.  It  has  been  recommended  that  strips  of 
plaster  of  Paris  be  applied  to  the  sides  of  the  head  and  neck 
toensure  rest  to  these  parts.     I  have  never  adopted  this  plan. 


TREATMENT    BY    KXTIRPATIOX.  273 

I  make  a  point,  however,  of  always  impressing  upon  the  patient 
before  the  operation  the  gTeat  importance  of  keeping  the  head 
and  neck  as  still  as  possible  for  the  first  two  davs  after  the 
operation. 

After  the  effects  of  the   anaesthetic   have   passed   off',  unless 
collapse  contraindicate  this  position,  the  patient  should  lie  in 


Fig.  95. — The  precediiii;- « Fig-.  94),  six  days  after  operation.     ( .SY-."  ApiK-udix, 
Case  111,  p.  3-52,  and  Eoyal  Free  Hosp.  Mus.  Xo.  xxii.  21.; 


a  semi-recumbent  position,  the  head  and  shoulders  being  well 
propped  up  \\  ith  pillows.  ]Most  patients  after  an  operation  for 
goitre  are  much  more  comfortable  in  this  position  than  Avhen 
kept  lying  down. 

A  sandbag  on  either  >.ide  of  the  head  helps  to  steady  it  and 
keep  it  in  position. 

The  after-treatment  of  the  case  is  u.sually  simple.  For  several 
hours  after  the  operation  no  food  should  be  given  ;  then  milk. 

.s 


274  THE   THYROID   GLAND. 

beef-tea,  and  other  fluids  may  be  given  for  a  day  or  two,  vmtil 
the  patient  can  swallow  solid  food  without  difficulty. 

Deglutition  is  usually  somewhat  painful  for  the  first  day  or 
two.  It  is  occasionally  advisable,  in  bad  cases,  to  feed  a  patient 
partly  or  wholly  by  the  rectum  for  a  few  days. 

My  patients  are  almost  always  allowed  to  get  up  on  the 
second  or  third  day  after  the  operation,  but  occasionally  bad 
cases  are  kept  in  bed  a  little  longer  than  this. 

The  drainage-tube  is  always  removed  at  the  end  of  twenty- 
four  hours,  except  in  the  few  cases  in  which  primary  union  is 
not  to  be  expected. 

The  stitches  should  be  removed  on  the  third  or  fourth  day 
after  the  operation.  By  the  end  of  a  week  the  patient  is  usually 
completely  well  and  able  to  return  home. 


CHAPTER  XVIII. 

MODIFICATIONS  OF  EXTIRPATION—RESECTION— 
RESECTION-EXTIRPATION— AMPUTATION. 

Mikulicz's  resection— Description — Results — Kocher's  resection- 
extirpation — Comjjai-ison  of  the  two  operations — Advantages  over 
other  operations — Amputation. 

Resection. — Mikulicz  of  Cracow  has  given  the  name  of  re- 
section to  an  operation  which  is  particularly  suitable  for  cases 
of  parenchymatous  goitre.  The  object  of  it  is  to  remove  the 
chief  part  of  one  or  both  lobes  and  to  avoid  any  risk  of  wounding 
the  recurrent  nerves.  At  the  same  time  enough  thyroid  tissue 
is  left  behind  to  carry  on  the  functions  of  the  gland. 

The  following  is  Mikulicz's  description  of  the  operation  as  he 
performed  it  upon  a  boy  of  sixteen  who  had  a  large  bilateral 
goitre  causing  much  dyspnoea  :  * 

"I  began  the  operation,"  he  says,  "intending  to  perform  the 
ordinary  one  of  removal  of  the  left  lobe,  and  hoping  to  be  able  to 
leave  the  right  intact.  In  the  course  of  the  operation,  however, 
it  became  evident  that  the  right  lobe  lay  partly  behind  the  sternum, 
and  would,  if  left,  prove  a  source  of  danger  to  the  patient.  So  in- 
stead of  doing  the  usual  extirpation,  I  resected  this  lobe  in  the 
following  manner.  First  of  all  it  was  isolated  as  far  as  possible 
in  the  usual  way  with  blunt  instruments.  The  smaller  blood 
vessels  were  tied  with  double  catgut  ligatures.  I  then  tied  the 
superior  thyroid  artery  and  vein  in  the  ordinary  manner  at  the 
summit  of  the  lobe  ;  also  the  superficial  vessels  passing  to  the  lower 
part  of  the  gland.  I  now,  by  means  of  short  snips  of  the  scissors, 
freed  that  portion  of  the  tumour  which  was  adherent  to  the  front 
and  side  of  the  trachea,  but  took  care  not  to  go  too  far  back,  so  as 
not   to  come    into    collision  with   the    recurrent   laryngeal   nerve. 

*  "  Ueber  die  Resektion  des  Kropfes  nebst  Bemerkungen  ueber  die  Folgezu- 
stande  der  Totalexstirpation  der  Schilddi-lise,"  Centralhlatt  f.  C'hir.,  Dec.  19. 
1885. 


^276  THF.   THYROID   (ILAND. 

Eventually  the  whole  tumour  was  attached  only  to  the  angle 
between  the  trachea  and  oesophagus,  where  it  covered  the  recurrent 
nerve  and  inferior  thyroid  artery.  This  attached  portion,  the  hilus 
of  the  gland,  I  treated  like  the  short  thick  pedicle  of  an  ovarian 
tumour.  I  had  already  on  previous  occasions  convinced  myself 
that  the  parenchyma  of  the  gland  was  extraordinarily  tolerant  of 
mechanical  injury,  and  this  knowledge  led  me  without  scruple  to 
put  a  row  of  ligaturfes  upon  the  gland  substance  itself.  While  my 
assistant  with  his  fingers  compressed  the  vessels  entering  the  hilus, 
I  split  the  pedicle  lengthwise  with  blunt  scissors  into  several  por- 
tions, seized  each  of  these  in  a  strong  pair  of  pressure  forceps  and 
placed  catgut  ligatures  in  each  of  the  clefts  so  formed.  Then  the 
goitrous  mass  was  cut  off  with  scissors,  leaving  a  pedicle  of  5—10  mm. 
(i-|^  inch)  in  length.  The  forceps  squeezed  out  nearly  all  the 
glandular  tissue,  leaving  in  their  grasp  little  but  connective  tissue. 
The  result  was  that  the  catgut  ligatures  could  easily  and  safely  be 
placed  round  the  separated  portions  of  the  pedicle.  Not  a  drop  of 
blood  came  away  from  the  cut  surfaces  ;  only  here  and  there  in  the 
intervals  was  a  little  oozing ;  this  slight  haemorrhage  was  easily 
stopped  by  the  application  of  a  few  ligatures.  The  remainder  of 
the  gland  had  now  shrunk  to  a  lump  about  as  large  as  a  chestnut, 
which  lay  in  the  angle  between  the  trachea  and  oesophagus. 
Neither  recurrent  nerve  nor  inferior  thyroid  artery  came  into  view' 
on  this  side." 

The  wound  healed  by  first  intention  and  the  patient  was  dis- 
charged ten  days  after  the  operation.  Breathing  was  easy,  the 
voice  was  weak  but  clear  and  the  vocal  cords  were  intact.  Four 
months  later  the  patient  was  seen  again ;  there  was  not  the 
slightest  trouble  in  breathing  and  the  voice  had  regained  its 
strength ;  the  neck  was  slender  and  presented  no  sign  of 
swelling.  At  the  time  of  the  last  report  seven  months  after  the 
operation,  the  condition  of  the  patient  was  in  every  respect 
satisfactory. 

Results  of  Mikulicz's  Resection. — Trzebicky  *  has  pub- 
lished details  of  twenty -three  cases  of  Mikulicz's  resection  per- 
formed by  Mikulicz  or  himself.  The  patients  were  nearly  all 
young  subjects,  fifteen  of  the  number  being  under  twenty-five 
years  of  age.  In  all  cases  dyspnoea  was  present,  in  many  it 
was  very  severe. 

*  "  Weitere  Erfahrimoeu  iiber  die  Resection  des  Kropfes  naeli  Miknlic-z." 
Langenbeck's  Arch.  f.  Id'in.  Chlr.,  1888,  vol.  xxxvii.  p.  49S. 


RESECTION.  277 

111  the  first  five  cases,  one  lobe  of  the  gland  was  completely 
removed,  then  the  other  was  resected. 

Nine  times  resection  of  one  lobe  only  was  performed,  nine 
times  both  lobes  were  simultaneously  resected. 

The  only  fatal  case  occurred  among  those  in  which  both  lobes 
were  resected.  The  patient  was  a  girl  aged  16  ;  after  resection 
of  the  right  lobe  and  during  the  separation  of  the  left  lobe  an 
attack  of  severe  dyspnoea  occurred  Avhich  necessitated  the  per- 
formance of  tracheotomy ;  the  operation  was  hurriedly  concluded 
and  the  wound  packed  with  iodoform  gauze.  Two  hours  later 
severe  recurrent  haemorrhage  took  place  from  the  right  side  of 
the  wound,  the  bleeding  could  not  be  controlled  and  the  patient 
died.  At  the  post  mortem,  it  was  found  that  the  ligature  had 
slipped  from  the  superior  thyroid  artery. 

Of  the  remaining  twenty-two  cases,  in  one  tracheotomy  had 
to  be  performed  ;  this  necessarily  prevented  primary  union  in 
the  wound,  which  nevertheless  healed  by  second  intention  without 
any  trouble. 

Twenty-one  times  the  wound  was  closed  and  drained ;  in  only 
one  of  these  did  the  wound  fail  to  heal  by  primary  union ;  this  was 
a  case  in  which  artificial  respiration  had  to  bt  performed  several 
times  in  the  course  of  the  operation.  Perfect  asepsis  could  not  be 
maintained  and  in  consequence,  suppuration,  with  necrosis  of  the 
stump,  took  place,  and  recovery  was  delayed  for  about  ten  weeks. 

In  the  remaining  twenty  cases,  with  the  exception  of  two  in 
which  a  little  superficial  suppuration  occurred,  healing  by  first 
intention  was  perfect.  In  three  cases,  the  otherwise  normal 
convalescence  was  complicated  by  an  attack  of  slight  inflamma- 
tion of  the  luiiffs  which  however  exerted  no  deleterious  effect 
upon  the  healing  of  the  wound.  As  regards  the  vocal  cords  in 
the  twenty-two  cured  cases,  they  were  intact  both  before  and 
after  the  operation.  In  nine  cases  there  was  either  marked  or 
slight  paralysis  of  the  cords  before  operation ;  in  four  of  these 
the  paralysis  remained  after  operation ;  in  two  cases  it  dis- 
appeared immediately  after  the  operation,  in  two  other  cases, 
only  after  the  lapse  of  a  few  months.  In  no  case  did  the 
operation  produce  any  deleterious  effect  upon  the  voice,  or  injury 
to  a  previously  healthy  vocal  cord. 

As  regards  after-results,  in  three  cases  no  information  could 


278  THE    THYROID    GLAND. 

be  obtained.  The  others  were  known  to  be  in  excellent  health, 
in  eight  cases  two  to  three  and  three-quarter  years  after  the 
operation,  in  five  cases  one  to  two  years,  and  in  six  cases  six 
months  to  a  year  afterwards. 

The  dyspnoea  in  all  cases  disappeared  almost  immediately 
after  the  operation  and,  so  far  as  is  known,  did  not  return.  In 
one  case,  an  attack  of  suffocative  dvspnoea  occurred  immediately 
after  the  operation.  In  no  case  was  there  any  report  of  a  return 
of  the  goitre  in  that  part  of  the  gland  which  was  left  behind, 
although  many  of  the  cases  were  examined  personally,  and  in 
many  others  information  upon  this  point  was  obtained  from  the 
local  doctor. 

In  no  case  did  any  impairment  of  general  health  (cachexia 
strumipriva  or  tetany)  follow  the  operation.  Of  the  fourteen 
patients  on  whom  the  operation  was  performed  on  both  sides, 
twelve  are  known  to  have  remained  in  good  health. 

Resection -extirpation. — This  name  has  been  given  by 
Kocher  *  to  an  operation  similar  to  that  of  ^Mikulicz.  As  the 
name  implies,  the  operation  is  a  combination  of  two  operations. 
Kocher  first  isolates  the  lateral  lobe  of  the  gland  as  in  extirpa- 
tion, tying  the  superior  and  inferior  thyroid  arteries  and  their 
corresponding  veins.  Then  the  isthmus  is  cut  through  at  its 
thinnest  part.  The  vessels  at  the  upper  and  lower  borders  are 
tied.  Then  a  section  is  made  through  the  gland  from  before 
back-wards,  beginning  near  the  junction  of  the  isthmus  and 
lateral  lobe  and  ending  on  the  posterior  surface  of  the  gland 
outside  the  line  of  the  recurrent  laryngeal  nerve. 

It  should  be  borne  in  mind  that  the  nerve  is  sometimes 
drawn  out  of  its  normal  groove  between  the  trachea  and  oeso- 
phagus and  is  stretched  over  the  posterior  surface  of  the  gland. 
Care  should  therefore  be  taken,  in  making  the  section  through 
the  posterior  surface  of  the  gland,  to  keep  well  away  fi'om  the 
nerve  lest  it  be  accidentally  wounded.  Kocher  lavs  stress  on 
the  importance  of  making  the  section  on  the  inner  side  of  the 
upper  horn  well  above  the  level  of  the  cricoid  cartilage,  so  as  to 
avoid  any  possibility  of  wounding  it. 

TTie  whole  of  the  mass  external  to  the  line  of  section  is  then 
removed  and  any  bleeding  vessels  are  tied. 

*  Correspynd enzhJatt  f.  schicel:.  Aer:tp.  Rasle.  1889.  p.  38. 


RESECTION-EXTIRPATION.  279 

During  the  whole  operation  the  isolated  thyroid  lobe  lies  in 
the  operator''s  left  hand  so  that  even  if  the  main  arteries  have 
not  previously  been  tied,  the  bleeding  can  be  controlled  by 
digital  compression,  and  ligatures  are  then  required  only  for  the 
cut  surface  of  the  stump. 

Comparing  Mikulicz's  with  Kocher''s  operation,  it  will  be  seen 
that  both  agree  in  leaving  intact  that  portion  of  the  gland  that 
lies  nearest  to  the  recurrent  nerve.  But  the  latter  surgeon 
avoids  separating  the  gland  from  the  surface  of  the  trachea  and 
especially  refrains  from  tying  up  masses  of  thyroid  tissue,  a 
practice  which  he,  quite  rightly  I  think,  strongly  condemns. 
He  says  that  not  only  does  this  practice  tend  to  prevent  that 
primary  union  which  is  all  important,  but  that  the  application 
of  the  ligatures  is  apt  to  endanger  the  safety  of  the  nerve. 
Such  an  accident  may  occur  even  when  the  greatest  care  is 
taken.  With  reference  to  this  point  Kocher  says  that  formerly, 
when  he  had  had  less  experience  in  removing  goitres,  he  had 
sometimes,  when  attempting  to  remove  one,  been  obliged  on 
account  of  bleeding  or  dyspnoea  to  ligature  the  pedicle  in  one 
or  more  masses,  in  order  to  cut  short  the  operation.  But  he 
had  noticed  tolerably  often  that  hoarseness,  from  paralysis  of 
the  vocal  cord,  was  produced  at  the  moment  of  applying  the 
ligature. 

The  chief  advantages  of  resection  and  resection-extirpation 
are  : 

(1)  That  they  enable  the  operator  to  remove,  when  necessaiy, 
both  lobes  of  a  goitre  and  yet  to  leave  behind  sufficient  gland 
tissue  to  carry  on  the  function  of  the  organ. 

(2)  By  leaving  intact  that  portion  of  the  gland  which  covers 
Ihe  recurrent  nerve,  they  lessen  the  risk  of  injuring  that 
:5tructure,i 

The  operation  of  resection-extirpation  is  the  one  which  I 
myself  now  usually  adopt  when  removing  a  parenchymatous 
goitre.     I  find  it  to  be  a  very  satisfactory  operation. 

Amputation. — This  is  a  term  used  for  an  operation  the 
indications  for  which  are  rarelv  present.  It  consists  in  simply 
cutting  off,  with  knife  or  scissors,  the  projecting  portion  of 
the  goitre.  It  is  suitable  only  in  some  few  cases  in  which  the 
tumour  forms  a  prominent  more  or  less  pedunculated  mass. 


CHAPTER    XIX. 

TREATMENT  BY  INTRA-GLANDULAR  ENUCLEATION 
AND  ITS  MODIFICATIONS. 

Intraglandular  enucleation:  Historx  —  (':i;^es  siutubU'  for  — 
Description  of  operation — Hi<?iuorrhage — Suture  of  ghmd.  Resection- 
enueleation :  Cases  suitable  for  —  Description  —  Advantages  and 
disadvantages.  Intracapsular  enucleation.  "Bloodless" 
enucleation.     "  Evidement "  :  Cases  suitable  for. 

By  intra -glandular  enucleation  is  meant  the  removal  of 
a  cystic  or  solid  tumour  from  the  interior  of  the  thyroid  gland, 
the  surrounding  glandular  tissues  being  left  intact. 

Enucleation  of  cysts  appears  to  have  been  performed  as  long- 
ago  as  1840  by  Porta  of  Pavia.* 

Billroth,  too,  more  than  thirty  years  ago  practised  a  similar 
operation. 

More  recently,  enucleation  of  cysts  was  recommended  and 
practised,  with  success,  by  Julliard  of  Geneva  and  Kottmann  of 
Soleure.  Burchkardt  of  Stuttgart,  MliUer  of  Tiibingen  and 
many  others  have  also  written  upon  the  subject  of  enucleation 
of  cystic  goitres. 

Solid  tumours  of  the  thyroid  gland  were,  however,  rarely 
treated  in  this  way  until  Professor  Socin  of  Basle,  some  twenty 
years  ago,  began  to  practise  enucleation  upon  these  also.  Dr. 
Keser  of  Vevey  contributed  materially  to  our  knowledge  of  the 
operation  by  the  publication  in  1887  of  an  excellent  mono- 
graph upon  the  subject.!  He  gave  full  details  of  thirty-seven 
enucleations  performed  by  Socin.  Of  these,  seventeen  were  for 
cvstic  and  twenty  for  solid  tumours. 

In  this  country  Mr.  Charters  Symonds,  in  1889,  brought  the 

*  •■  Delle  nmlattie  e  delle  ojjerazioni  della  gjuandola  tiroidea."  Luigi  Porta. 
Milan.  1849. 

t  "  L'enueleation  on  extirpation  intra-glandulaire  du  goitre  ]>arenchyinateux," 
Samuel  Keser,  Paris,  1887. 


INTRA-GLANDULAR   IINUCLEATION. 


281 


subject  prominently  before  our  notice  by  publishing  an  excellent 
series  of  cases.* 

In  the  last  few  years  the  operation  has  been  practised  exten- 


FiG.  9G. — Showing  n  Transverse  Sear  low  down  iu  the  ueck,  one 
month  after  enncleiition  of  a  left  cystic  adenoma  as  large  as  a  duck's 
eg'g'.  The  tumour  had  caused  considerable  dyspnoea.  (,S'ee  Appendix. 
Case  54,  p.  346.) 

sively  by  very  many  surgeons  and  its  excellence  thoroughly 
proved. 

The  operation  of  enucleation  depends  for  its  feasibility  upon 
the  following  facts  : 

Many  goitres  consist,  not  of  an  enlargement  of  one  or  both 
lobes  of  the  thyroid  gland,  but  of  a  circumscribed  timiour  lying 
in  more  or  less  healthy  gland  tissue.  Sometimes  the  tumour 
is  a  cyst,  unilocular  or  multilocular  ;  sometimes  it  is  solid,  of  an 

*  ••  Eight  Cases  of  Thyroid  Cysts  and  Adenomata  treated  by  Euueleation," 
Trans.  Clin.  >S:if.  vol.  xxiii.  p.  .51. 


282  THE    THYROID    GLAND. 

adenomatous  nature,  like  the  corresponding  tumours  which  are 
found  in  the  breast  and  other  glandular  organs. 

Of  whatever  nature,  the  tumour  is  surrounded  by  a  well- 
marked  capsule  composed  of  connective-tissue,  and  of  thyroid 
tissue  altered  and  atrophied  by  pressure. 

It  is  owing  to  the  existence  of  this  capsule  that  enucleation 
can  be  performed,  the  tumour  alone  being  shelled  out  without 
interference  with  the  remainder  of  the  gland. 

The  nature  of  the  capsule  surrounding  the  goitrous  tumour 
varies  according  to  the  size  and  position  of  the  tumour.  If  the 
latter  be  small  and  deeply  seated,  it  is  surrounded  by  what  is 
obviously,  to  the  naked  eye,  thyroid  tissue.  If,  on  the  other 
hand,  the  tumour  be  large  and  project  much,  it  will  probably  be 
covered  on  its  superficial  aspect  by  what  appears,  at  first  sight, 
to  be  merely  connective  tissue,  but  which  is  really  a  thin  layer 
of  thyroid  tissue.  Whether  thick  or  thin,  then,  the  capsule  of 
the  tumour  is  composed  everyAvhere  of  thyroid  tissue,  the 
presence  of  which  can  easily  be  demonstrated  by  means  of  the 
microscope. 
(^  It  is  very  important  that  the  distinction  between  the  con- 
nective tissue  capsule  of  the  gland  and  the  glandular  capsule  of 
the  tumour  proper,  should  be  carefully  borne  in  mind.    ) 

The  earlier  stages  of  the  operation,  that  is  down  to  the 
exposure  of  the  thyroid  gland,  are  the  same  as  in  extirpation 
already  described. 

An  incision  is  now  made  through  the  capsule  of  the  gland 
and  through  the  gland  itself,  until  the  surface  of  the  tumour 
has  been  reached. 

Any  large  vessels  that  may  be  seen  on  the  surface  of  the 
gland  may  be  clamped  before  this  incision  is  made,  or  they  may, 
perhaps,  to  some  extent  be  avoided  by  placing  the  incision  in  a 
part  where  the  vessels  are  least  conspicuous.  As  a  rule,  the 
incision  should  be  made  directly  over  the  most  prominent  part 
of  the  tumour  without  much  attention  to  the  vessels. 

If  the  capsule  of  the  tumour  be  very  thin  and  transparent,  as 
is  often  the  case,  it  may  be  closely  adherent  to  the  capsule  of 
the  gland  and  the  two  may  appear  to  form  but  a  single  layer, 
which  may  be  closely  adherent  to  the  tumour  itself.  As  it  is 
very  important  that  the  surface  of  the  tumour  be  distinctly 


INTRA-GLANDULAR   ENUCLEATION. 


28^ 


recognised,  it  is  sometimes  advisable  to  begin  the  incision  somewhat 
higher  up,  where  the  glandular  layer  is  thicker  and  more  easily 
distinguished  by  its  reddish  colour  from  the  subjacent  tumour. 
The  tumour  itself  is  most  easily  recognised  bv  its  colour,  which 
is  almost  invariably  different  from  that  of  the  healthy  gland. 


■'i^s.mw 


Fig.  97. — Eiglit  lobe  of  the  tliyroiil.  removed  bv  extlrpatiou,  on  account  of 
dyspnoea, from  a  womau aged  25.  It  contains  a  Cystic  Adenoma, 
which  miglit,  with  advaiitage,  Iiave  been  removed  by  enucleation. 
(Case  11.*     See  Eoyal  Free  Hosp.  Mus.  Xo.  xxii.  4i.)    (Xattiral  size.) 

It  is  generally  of  a  dark  blueish  hue  from  the  presence  of 
blood-stained  fluid  within  it ;  it  is  frequently  of  a  light  yellowish 
colour",  especially  if  the  tumour  be  old  and  have  thick  walls.  It 
is  only  in  the  case  of  soft,  very  vascular,  solid  adenomata  that 
the  colour  of  the  tumour  at  all  resembles  that  of  the  healthy 
gland. 


Published  in  the  Brit.  Mp(1.  Jovrn..  Julv 


1900. 


J84. 


THE   THYROID   GLAND. 


The  operator  must  cut  boldly  through  the  gland  until  the 
surface  of  the  tumour  has  been  clearly  defined.  He  must  be 
careful,  however,  not  to  cut  into  the  tumour  itself,  and  thus 
miss  the  proper  layer  between  tumour  and  gland,  in  which 
alone  enucleation  can  be  properly  performed. 

As  soon  as  the  tumour  has  been  reached,  the  knife  is  laid  aside 
and  the  tumour  shelled  out  of  its  bed  with  finders  or  with  a 
blunt   instrument,  such  as  a  goitre  scoop  {see  Fig.  98).     In  the 


Fig.  98. — Goitre  SCOCps,  usud  chiefly  for  tlic  enucleation  of  cysts 
and  adenomata.     A.   KoclierV.     b.   Tlie  >:ame.  sliL^htlv  modified. 


absence  of  a  better  instrument,  the  handle  of  a  scalpel  or  a 
closed  pair  of  curved,  blunt  pointed  .scissors,  will  do  very  well 
for  the  enucleation. 

Some  operators  think  it  desirable  to  remove  the  tumour  in  an 
unbroken  condition.  I  attach,  however,  but  little  importance 
to  this.  If  the  tumour  is  soft  and  contains  fluid,  as  is  very 
often  the  case,  it  is  very  liable  to  be  ruptured  during  the 
removal.  In  the  case  of  a  tumour  which  is  suspected  to  contain 
fluid,  I  often  begin  by  plunging  a  knife  or  some  blunt  instru- 
ment into    the  interior  to    let    out    this   fluid.     Throuoh    the 


INTRA-GLANDULAR   ENUCLEATION. 


285 


O  -^ 

PI 

(B  .; 

•iH  > 

'o  ^ 

o3  = 


O  ~ 

o  ^ 

pi 

H  § 


286  THE   THYROID   GLAND. 

opening  thus  made  I  put  the  left  forefinger  and  thus  grasping 
the  wall  of  the  tumour  between  the  finger  and  thumb,  draw  it 
forwards  and  effect  the  rest  of  the  eimcleation  by  peeling  the 
gland  away  from  the  tumour  with  a  pair  of  dissecting  forceps 
held  in  the  right  hand. 

Or  the  wall  of  the  tumour  may  be  grasped  with  broad  forceps 
instead  of  with  the  finger  and  thumb. 

In  many  cases  of  soft  solid  tumours  and  in  some  cysts,  the 
^\"all  is  so  thin  that  it  tears  readily  when  traction  is  made  upon 
it.  In  these  cases  it  is  best  to  place  several  pairs  of  forceps  on 
the  cut  edges,  so  as  not  to  exert  too  much  traction  upon  any 
one  point. 

The  preliminary  evacuation  of  the  contents  of  the  tumour, 
by  diminishing  its  size,  often  enables  the  operator  to  draw  the 
tumour  well  forwards  out  of  the  wound  through  a  comparatively 
small  incision.  I  have  often,  by  adopting  this  manoeuvre, 
succeeded  in  removing  large  cystic  and  even  solid  tumours 
through  skin  incisions  considerably  shorter  than  the  diameter  of 
the  tumour  itself.  It  must  be  remembered,  however,  that  inter- 
ference with  the  interior  of  the  tumour  often  causes  smart 
haemorrhage,  and  that  no  attempt  can  be  made  to  control  this 
hannorrhage  until  the  tumour  has  been  removed.  Before 
attempting  to  enucleate  a  tumour  through  a  small  incision,  the 
operator  should  feel  certain  that  the  tumour  will  permit  of  rapid 
and  easy  enucleation  ;  otherwise  he  may  get  into  serious  trouble 
wdth  the  haemorrhage. 

In  performing  the  enucleation,  whether  by  finger,  scoop,  or 
forceps,  the  operator  must  be  careful  to  keep  always  close  to  the 
external  surface  of  the  tumour,  and  not  to  let  the  point  of  his 
instrument  wander  through  the  gland  tissue  into  the  tissues 
outside  the  gland.  This  is  easily  done  if  the  gland  be  much 
atrophied  and  form  only  a  thin  layer  over  the  tumour. 

Directly  the  tumour  has  been  removed  attention  must  be 
directed  to  the  haemorrhage,  which  is  often  profuse  during  the 
few  moments  occupied  by  the  actual  enucleation.  A  sponge 
should  be  placed  in  the  cavity  formerly  occupied  by  the  tumour 
and  the  whole  cavitv  drawn  forwards,  either  by  means  of  the 
forceps  previously  placed  on  the  cut  edges,  oi'  by  forceps  applied 
to  the  inner  surface  of  the  posterior  wall.     It  is  often  a  good 


INTRA-GLANDULAR   ENUCLEATION. 


287 


o 

^ 

a 

^ 

<u 

•^ 

'xi 

r; 

<\ 

P_^ 

"B 

< 

J-H 

O 

-c 

QQ 

■-^ 

<D 

bD 

i 

U 

.^ 

_o 

d 

■5 

tw 

p 

o 

OB 

a 

o 

-+;^ 

'■<j 

'S 

r! 

a 

O 

t— ( 

o 

o 

s 

P! 

p 

1^ 

^ 

^      ^^      ^ 


2  B  ^ 

_^   'S   "3 


288  THE    THYROID    (iLAM). 

plan  to  evert  the  bottom  of  the  eavitv  })v  pushing  its  posterioi- 
wall  forwards  from  behind  bv  fingers  plaeed  outside  the  gland, 
or  even  in  the  posterior  triangle  of  the  neck.  The  haemorrhage 
is  thus  kept  well  under  control,  while  the  bleeding  vessels  are 
picked  up  one  after  another  and  securely  tied. 

It  is  of  the  greatest  hnjjortance  that  all  haemorrhage  .should  he 
eompletely  ari'ested  before  the  ivound  i.s  elosed.  If  oozing  be 
allowed  to  take  place  into  the  wound  primary  union  is})revented 
and  serious  trouble  may  follow. 

^^'hen  the  wound  is  quite  clean  and  free  from  blood  it  must 
be  closed.  This  is  best  effected  by  three  layers  of  fine  sutures, 
one  in  the  gland,  one  in  the  muscles,  and  a  third  in  the  skin. 
The  sutures  in  the  gland  should  be  passed  transversely  in  and 
out  se\eral  times  through  the  wall  of  the  cavity,  so  as  to 
obliterate  as  far  as  ])ossible  the  space  in  which  the  tumour  lay, 
and  thus  prevent  the  accumulation  of  blood  within  it.  The 
layer  of  gland  forming  the  wall  of  the  cavity  may  be  very  thin, 
and  care  must  therefore  be  taken  not  to  transfix  or  include  in 
the  suture  any  of  the  structures  lying  immediately  outside  it, 
especially  the  internal  jugular  vein  and  the  recurrent  laryngeal 
nerve.  The  subsequent  steps  of  the  operation  are  the  same  as 
in  extirpation.  If  the  cavity  to  be  closed  is  small  and  the 
wound  is  a  perfectly  clean  one,  drainage  need  not  be  employed. 
If  the  cavity  is  large,  drainage  for  twentv-foiu-  hours  is 
advisable. 

The  after  treatment  of  the  case  differs  m  no  essential  point 
from  that  of  extirpation. 

Modifications  of  Enucleation.  Resection- enuclea- 
tion.— The  most  important  modification  of  enucleation,  and  one 
which  I  frequently  employ,  is  that  which  has  been  described  by 
Kocher  under  the  name  of  resection-enucleation.  Just  as 
resection-extirpation  is  an  extirpation  in  which  the  inner  and 
back  part  of  the  lobe  is  left  intact,  so  is  resection-enucleation  an 
enucleation  which  leaves  behind  this  portion  of  the  lobe  but 
removes  all  the  rest.  It  is  suitable,  of  course,  only  for  encap- 
suled  tumours,  and  is  most  useful  in  cases  of  very  large  tumours. 
The  enucleation  of  a  very  large  thyroid  tumour,  if  performed  in 
the  ordinary  manner,  may  involve  considerable  haemorrhage 
from  the  surface  of  the  vast  cavity  in  which  the  tumour  lay. 


MODIFICATIONS    OF   ENUCLEATION. 


289 


290  THE   THYROID   GLAND. 

Moreover,  a  very  large  tumour  has  in  its  growth  so  compressed 
the  gland  tissue  lying  over  it,  that  the  latter  is  functionally  well 
nigh  useless.  In  resection-enucleation  a  large  portion  of  this 
thinned  glandular  capsule  is  removed  with  the  tumour.  The 
latter  is  enucleated  only  from  its  connections  at  the  inner  and 


Fig.  105. — The  preceding'  (Fiy.  103)  oue  year  alter  operation.     (Sec  Appendix. 
Case  62,  p.  3i6,  and  Royal  Free  Hosp.  Mns.  No.  xxii.  47.) 

back  part.     Reference  to  Figs.  106  and  107  will  make  the  steps 
of  the  operation  clear. 

A  vertical  incision  is  made  along  the  line  aa*  on  the  front 
and  inner  part  of  the  tumour.  Enucleation  is  then  performed 
on  the  inner  side  only  of  the  tumour.  When  the  posterior  wall 
ot  the  tumour  has  been  reached  the  glandular  capsule  is  again 
cut  through,  at  a  point  well  external  to  the  recurrent  laryngeal 

*  I  usually  make  this  incision  a  little  further  outwards  thau  is  sho^vn  in  the 
tiji'ure. 


MODIFICATIONS    OF   ENUCLEATION.  291 

nerve.     The  tumour,  with  all  the  rest  of  its  glandular  capsule 

h 


Fig.  106. — Diagrammatic  horizontal  section  throngli  tlic  thyroid  f;]autl,  trachea, 
oesophagu?, and  reciu-rent  nerve,  to  illustrate  Reseetion-Enucleation- 
The  right  lohe  of  the  gland  is  occupied  hy  an  eucapsiiled  tumoiu-  which  is 
embedded  in  a  thin  layer  or  capsule  of  gland  tissue  (c).  At  a  is  seen  the 
Iilace  on  the  front  of  the  giaud  wliere  this  gland  capsule  should  he  cut 
Terticall.y.  At  6  is  the  corresponding-  place  where  the  gland  is  cut  pos- 
teriorly. Along-  the  line  adb  the  surface  of  the  tumour  has  to  he  separated 
fi-om  the  healthy  gland  tissue  on  its  inner  side.  The  rest  of  the  glandular 
capsule  acb  Is  removed  with  the  tumour.     (After  Kocher.) 


Pig.  107. — Front  view  of  a  goitre  similar  to  that  of  Fig-.  106.  The  vertical  line 
aa  shows  the  position  of  the  incision  througli  the  anterior  part  of  the 
gland  capsule.  The  dotted  line  bb  shows  the  line  of  incision  through  the 
posterior  part  of  the  capsule.  If  the  upper  horn  of  the  gland  is  not  to  be 
removed,  the  incisions  are  made  along-  the  lines  aae  in  front  and  fbb 
behind.     (After  Koclier.) 

still  attached  to  it,  is  then  removed.  Various  thyroid  vessels 
have  to  be  ligatured  in  the  course  of  the  operation,  as  is  done  in 
extirpation. 


292  THE   THYROID   GLAND. 

The  operation  may  be  variously  modified  according  as  the 
tumour  Hes  at  the  upper  or  lower  part  of  the  gland  {see  Fig.  107), 
the  object  always  being  to  leave  behind  healthy  gland  tissue  and 
to  remove  the  tumour  and  the  atrophied  glandular  tissue  lying- 
in  immediate  contact  with  it.  After  removal  of  the  tumour  I 
frequently  unite  with  a  few  points  of  suture  the  anterior  and 
posterior  edges  (aa,  bb)  of  the  remaining  gland.  This  tends  to 
diminish  still  further  the  size  of  the  wound.  Resection-enucle- 
ation,  when  compared  with  simple  enucleation,  has  therefore 
the  advantages  that : 

(1)  It  lessens  the  severe  haemorrhage  that  often  occurs  in  the 
separation  of  the  tumour  from  its  capsule. 

(2)  The  capsule  of  functionally  useless  gland  tissue  is  not  left 
in  the  wound.  Thus  the  very  deep  sutures  necessary  to  bring 
the  sides  of  this  capsule  into  contact  to  secure  primary  union 
may  be  avoided. 

On  the  other  hand,  the  cellular  tissue  of  the  neck  is  opened 
up  more  freely  in  resection-enucleation  than  in  enucleation. 

Intra-capsular  Enucleation  (Julliard).  —  JulHard  of 
Geneva  *  has  advocated  a  method  of  removing  goitres  which,  in  his 
hands,  appears  to  have  proved  very  successful.  Instead  of  keeping 
outside  the  capsule  as  Kocher  does  in  his  operation  of  extirpa- 
tion, Julliard  removes  the  tumour  from  within  the  capsule. 
This  proceeding  must  not  however  be  confounded  with  Socin's 
enucleation.  Socin  removes  the  goitrous  tumour  from  within 
its  glandular  capsule,  that  is  the  capsule  formed  by  thyroid 
tissue.  Julliard's  operation  is  really  not  a  true  enucleation  but 
a  variety  of  extirpation,  the  tumour  being  however  removed 
from  within  its  capsule. 

For  my  own  part  I  cannot  but  think  that  Julliard's  operation 
is  inferior  to  Socin's  on  the  one  hand  and  to  Kocher's  on  the  other. 
Inferior  to  Socin's  in  that  it  removes  not  merely  the  tumour  but 
also  surrounding  tissues :  inferior  to  Kocher's,  because  by  opening 
the  capsule,  haemorrhage  is  produced  which  might  have  been 
avoided  by  keeping  outside  the  capsule. 

"  Bloodless  "  Enucleation  (Bose). — Bose  of  Giessenf  has 

*  ••  Trente  et  iine  extirpations  de  goitres,"  Rev.  de  Ch'tr.,  Paris,  1883,  iii.  585. 
f  "  Die  kunstliche  Blutleere  bei  Ausschalung  von  Ki-opfkuoten,"  Centralbl.  f. 
Chir.,  1889,  xvi.  p.  1. 


"BLOODLESS"    ENUCLEATION.  293 

devised  a  so-called  "  bloodless  method  of  performing  enucleation." 
It  is  intended  to  facilitate  enucleation  by  enabling  the  operator 
to  see  more  clearly  the  limits  between  healthy  and  diseased 
thyroid  tissue.  He  isolates  one  lobe  of  the  gland  sufficiently  to 
enable  it  to  be  raised  up  from  its  bed.  The  amount  of  blood  in 
it  quickly  diminishes  as  is  the  case  when  one  of  the  limbs  is  held 
in  the  vertical  position  for  a  few  minutes.  An  elastic  ligature 
is  then  passed  round  the  tumour  at  a  point  a  little  beyond  its 
widest  part  and  then  fastened.  A  piece  of  ordinary  rubber 
drainage  tubing  is  used  for  this  purpose. 

The  gland  thus  emptied  of  much  of  its  blood  can  then  be 
incised  and  the  tumour  or  tumours  dissected  out  without 
difficulty.  The  elastic  ligature  also  assists  by  squeezing  the 
tumours  out  towards  the  wound.  The  bleedino;  which  occurs 
after  the  ligature  has  been  relaxed  is  said  to  be  but  trifling. 
Bose's  method  is  of  course  not  applicable  to  cases  in  which'  the 
goitre  is  deeplv  seated  and  fixed.  The  whole  proceeding  seems 
to  be  somewhat  rough  and  unsurgical  and  is  open  to  the  serious 
objection  that  it  involves  far  more  disturbance  of  the  gland  and 
more  opening  up  of  the  cellular  tissue  of  the  neck  than  in  the 
ordinary  enucleation.  I  have  myself  never  employed  this  method 
of  enucleation. 

Evidement.  —  Under  the  name  of  evidement  (evacuatio 
striimce)  Kocher  has  described  a  proceeding  which  differs  slightly 
from  enucleation. 

In  the  latter  operation  the  capsule  only  is  at  first  divided,  the 
tumour  being  then  isolated  and  removed. 

In  evacuation,  the  tumour  itself  is  "  cut  across  in  its  whole 
thickness,  the  two  halves  being  then  extracted  by  means  of 
fingers  and  sharp  spoons.^' 

This  operation  is  however  of  only  limited  applicability. 
According  to  the  originator  of  it,  it  may  on  account  of  its 
simplicity  be  emploved  with  advantage  in:  (1)  Isolated  small  of 
large  tumours  of  soft  consistence,  lying  in  comparatively  healthy 
gland  tissue  ;  (2)  Large  tumours  lying  in  goitres  not  freely 
movable,  even  though  the  goitres  may  contain  numerous 
other  nodules,  a  condition  which,  had  the  goitre  been 
movable,  would  have  demanded  extirpation ;  in  order  to 
justify   the  performance    of   evacuation,    however,    the    tumour 


294  THE    THYROID    (tLAXD. 

must    be    soft    and   have    numerous    vascular  connections   with 
surrounding  parts. 

I  have  mvself  employed  this  method  in  a  few  cases.  These 
have  been  chieflv  cases  of  very  soft  adenoma  in  which  owing  to 
the  friabilitv  of  the  tumour  simple  enucleation  would  have  been 
difficult.     {See  cases  72  and  80  on  p.  348.) 


CHAPTER  XX. 

COMPLICATIONS  OF  OPERATIONS  FOR  REMOVAL 
OF  NON-MALIGNANT  GOITRE. 

I.  Accidents  occurring'  during  ttie  operation  :  Sudden 
death — Causes  of — Cases — Importance  of  avoiding  traclieotomy,  if 
possible — Primary  haemorrhage  in  extirpation,  in  enucleation — Injury 
to  nerves — Recurrent  laryngeal  nerve,  sympathetic,  vagus — Injury  to 
trachea,  pleura,  pharynx  and  oesophagus.  II.  Complications 
occurring  shortly  after  the  operation  :  Secondary  hasmor- 
rliage — Recurrent  hemorrhage — Sepsis — Treatment  of — Rapid  pulse 
"\vith  restlessness — Causes  of — Late  compression  of  recurrent  nerve  by 
scar — Tetany. 

These  may  conveniently  be  divided  into  the  following  groups  : 

I.  Accidents  occurring  during  the  operation. 

II.  Complications  occurring  shortly  after  the  operation. 

III.  Remote  complications. 

I.  Accidents    occurring'    during    the    Operation. — 

These  are  generally  caused  by  dyspnoea,  by  the  angesthetic,  or 
by  injury  of  blood-vessels,  nerves  or  other  important  structures 
in  close  proximity  to  the  goitre. 

Sudden  death  during  the  operation  is  the  most  serious  of 
these  accidents.  It  occurs  almost  exclusively  in  cases  in  which 
severe  dyspnoea  is  present  before  the  operation  has  been  begun, 
or  in  which  there  is  a  history  of  severe  paroxysmal  attacks  of 
dyspnoea.  Many  such  cases  have  been  recorded  and  many  others 
remain  unrecorded.  This  calamity  is  due  usually  either  to  the 
administration  of  an  anaesthetic  in  an  unsuitable  case,  to  the 
severity  of  the  dyspnoea  or  to  syncope.  Very  severe  dyspnoea 
may  have  been  present  before  the  operation  and  may  lead  to 
death  before  the  operator  has  had  time  to  give  any  relief ;  or 
dyspnoea  may  be  suddenly  induced  by  undue  traction  or  pressure 
upon  the  trachea  during  the  course  of  the  operation  ;  or  may  be 


296  THE   THYROID  GLAND. 

caused  by  spasm  of  the  glottis  from  irritation  of  the  recurrent 
laryngeal  nerves  (a  rare  cause).  Finally  dyspnoea  may  be  due 
to  syncope  caused  bv  irritation  of  the  vagus  or  its  cardiac 
branches,  acting  perhaps  upon  a  heart  already  much  damaged 
by  prolonged  respiratory  distress. 

Sometimes  death  occurs  at  the  very  beginning  of  the  operation 
immediately  after  the  first  incision  through  the  skin  has  been 
made.  Juiliard  records  a  case  of  this  kind.  The  patient  was  a 
man  aged  26  with  severe  dvspnoea.  I  have  recorded  *  a  similar 
case  which  unfortunatelv  occurred  to  myself  many  years  ago. 
The  patient  was  an  elderly  woman  who  had  had  a  lai'ge  goitre 
for  many  years.  In  the  last  few  months  it  had  given  her  much 
more  trouble  and  she  had  had  many  severe  attacks  of  dyspnoea. 
An  attack  which  occurred  just  before  I  first  saw  the  patient  was 
so  severe  that  her  medical  attendants  who  witnessed  it  told  me 
that  they  did  not  expect  she  would  have  survived  it.  An 
operation  for  the  removal  of  the  goitre  was  undertaken. 
Chloroform  was  administered  and  the  usual  oblique  incision  had 
just  been  made  when  breathing  suddenly  stopped.  Tracheotomy 
was  immediately  performed  and  artificial  respiration  kept  up  for 
some  time,  but  without  avail.  I  have  no  doubt  now  that  it 
would  have  been  better  to  have  done  this  operation  without 
chlorofoi'm,  using  only  a  local  anaesthetic.  The  only  other  case 
of  death  during  a  goitre  operation  that  has  occurred  to 
myself  was  that  of  a  woman  aged  43  who  had  a  parent^hyma- 
tous  goitre  and  had  had  severe  paroxysms  of  dyspnoea.  Chloro- 
form was  administered  and  the  superior  thyroid  vessels  and 
middle  thyroid  veins  had  been  tied  and  divided.  The  tumour 
was  being  lifted  up  out  of  its  bed  preparatory  to  tying  the 
inferior  thyroid  artery  when  the  patient  suddenly  died,  twelve 
minutes  after  the  beginning  of  the  operation.  In  both  these 
cases  the  chloroformists,  although  anaesthetists  of  considerable 
experience,  had,  I  believe,  never  before  given  an  anaesthetic  for 
a  goitre  operation.  Both  cases  were  among  my  earliest  opera- 
tions. 

The  following  case,  of  which  I  was  a  witness,  although  taking- 
no  part  in  the  operation,  occurred  at  St.  Bartholomew's  Hospital 

*  ''Lectures  on  Goitre  at  the  Eoj-al  College  of  Surgeons,"  Brit.  Med.  Jcuni.. 
June  1891. 


ACCIDENTS   DURING   THE   OPERATION.  297 

in  1896 :  "  A  woman  aged  26  had  had  for  four  years  a  swelHng 
of  the  thyroid  with  some  dyspnoea,  especially  at  night.  She 
was  a  healthy  voung  woman  with  a  cystic  adenoma  as  large  as  a 
hen's  egg  at  the  lower  part  of  the  right  thyroid  lobe.  When 
quiet  she  had  no  stridor,  but  after  exertion  or  on  taking  a  deep 
breath  the  tumour  descended  behind  the  sternum  and  caused 
audible  stridor.  When  the  tumour  was  in  the  latter  situation 
it  was  no  longer  visible.  Intra-glandular  enucleation  was  per- 
formed ;  the  operation  lasted  only  a  few  minutes,  but  in  the 
course  of  it  the  patient  stopped  breathing  and  could  not  be 
brought  round  again,  in  spite  of  tracheotomy  and  other  efforts 
to  restore  her.  The  cessation  of  respiration  occurred  just  at 
the  moment  when  the  tumour  was  being  enucleated  with  the 
finger."  * 

In  King's  College  Hospital  Reports  "f  is  a  brief  account  of  a 
similar  death  during  the  removal  of  a  fibro-adenoma  from  a 
female  patient.  "The  death  was  due  to  sudden  dyspnoea  owing 
to  the  pressure  of  the  growth  during  the  operation." 

The  knowledge  of  these  cases  and  of  a  good  many  others, 
some  published  and  some  communicated  privately  to  me,  have 
led  me  to  take  a  somewhat  serious  view  of  the  question  of  a 
general  anaesthetic  in  cases  where  there  is  much  dyspnoea.  I 
believe  that  when  dyspnoea  is  severe  there  may  be  grave  danger 
in  the  administration  of  a  general  anaesthetic,  especially  if  the 
administrator  is  not  thoroughly  familiar  with  goitre  operations. 
Whenever  possible  I  prefer  either  to  have  a  skilled  anaesthetist 
thoroughly  familiar  with  these  operations,  or  in  some  cases  of 
bad  dyspnoea  to  dispense  altogether  with  general  anaesthesia, 
using  only  cocaine,  eucaine,  or  morphia. 

The  danger  of  the  supervention  of  sudden  dyspnsea  or  syncope 
appears  to  be  specially  great  just  at  the  moment  when  the 
tumour  is  being  lifted  up  or  turned  over.  It  is  at  this  time 
that  the  flattened  and  narrowed  trachea  is  most  likely  to  be 
still  further  compressed.  It  is  well,  therefore,  that,  at  this 
stage  of  the  operation,  both  operator  and  anaesthetist  shotdd 
pay  especial  attention  to  the  respiration  and  circulation. 

If  the  dyspnoea  becomes  very  urgent,  tracheotomy  may  become 

*  St.  Burt.  Hmq).  Rej}.-^..  xxxiii.  1897,  appendix  ii.  p.  175. 
t  Vol.  ii.  189i-5. 


2.qs  thp:  thyroid  gland. 

imperative.  But  it  is  very  rarely  necessary,  and  it  should  be 
remembered  that  the  performance  of  tracheotomy  g-reatly  increases 
the  danger  of  the  operation,  since  the  all-important  primary 
union  is  therebv  necessarily  prevented. 

It  is  obvious  that  in  some  cases  in  which  the  operation  is 
unusually  severe  and  prolonged,  or  in  which  the  patient's  general 
condition  is  very  bad,  death  mav  occur  from  shock,  dyspnoea, 
or  haemorrhage  before  or  very  soon  after  the  conclusion  of  the 
operation. 

The  dano'er  is  naturally  greater  if  the  o-oitre  be  of  enormous 
size,  or  very  fixed,  or  if  the  patient  be  very  old.  The  following 
case  is  an  example  of  what  mav  occur  when  the  operation  is 
postponed  until  the  patient  is  m  extremis.  It  has  been  kindly 
communicated  to  me  by  Mr.  Stanley  Boyd,  who  was  present  at 
the  operation,  although  he  was  not  himself  the  operator  : 

The  patient  was  a  middle-aged  ladv  who  had  had  a  large  bilateral 
goitre  for  many  years.  In  the  last  ten  years  she  had  been  under 
the  care  of  a  phvsician  who  had  fi-om  time  to  time  injected  tincture 
of  iodine  without,  however,  causing  any  decrease  \i\  the  size  of  the 
tumour. 

Bi'eathing  had  for  some  years  been  getting  gradually  worse,  and 
there  had  been  much  stridor  for  a  year  or  more.  In  the  autumn 
of  1890  she  had  an  attack  of  bronchitis,  and  her  condition  rapidly 
became  extremely  serious.  It  was  then  recommended  by  the 
injector  of  iodine  that  one  half  of  the  gland  should  be  removed, 
and  a  well-known  London  surgeon,  now  deceased,  was  asked  to  go 
down  into  the  country  to  perform  the  operation. 

The  patient  was  found  sitting  up  in  bed  with  a  hvid  face,  gasping 
for  breath.  Loud  stridor  was  present,  and  it  was  obvious  that  the 
trachea  Avas  greatly  compressed  by  the  goitre. 

It  seemed  evident  that  unless  something  was  speedily  done  to 
relieve  the  dvspnoea,  the  patient  would  certainly  die  very  soon. 

The  extreme  gravity  of  the  case  ha\ing  been  explained  to  the 
patient's  friends,  and  it  being  their  Avish  that  the  attempt,  however 
hazardous,  should  be  made  to  save  her  life,  extirpation  of  the  goitre 
was  begun.  The  difficulties  of  the  operation  were,  however,  so 
great,  and  the  dvspnoea  became  so  severe,  that  tracheotomj'  seemed 
imperative.  A  deep  incision  was  therefore  made  through  the  very 
broad  isthmus  down  to  the  trachea,  which  was  found  to  be  so  much 
compressed  that   its  walls  were  almost  in   contact.     Tracheotomy 


PRIMARY    HAEMORRHAGE.  299 

and  artificial  respiration  were  performed^  but  in  vain.     The  unfor- 
tunate patient  gave  a  few^  gasps  and  expired. 

Primary  Heemorrhag'e  may  prove  to  be  a  serious  com- 
plication, if  the  operation  be  a  very  long  and  tedious  one,  or  if 
the  goitre  be  vei-y  large.  In  extirpation,  haemorrhage  ought  never 
to  be  severe,  if  sufficient  care  be  taken  to  tie  or  clamp  all  the 
])rincipal  vessels  hefore  they  are  cut.  The  surgeon  who  operates 
by  cutting  freely,  and  then  picking  up  and  tying  the  vessels 
that  bleed,  will  cause  a  great  deal  of  unnecessary  loss  of  blood, 
and  often  seriously  endanger  the  life  of  his  patient.  It  cannot 
be  too  strongly  insisted  upon  that  in  this  ojjeration  every  vessel 
of  importance  must  he  tied  or  clamped  hefore  it  is  divided.  In 
this  way  even  large  and  very  vascular  goitres  mav  be  removed 
with  the  loss  of  less  than  an  ounce  of  blood.  A  knowledge  of 
the  exact  position  in  which  the  principal  vessels  are  to  be  found, 
is.  of  course,  of  much  importance. 

With  enucleation  the  case  is,  of  course,  different.  The  tumour 
is  in  this  operation  generall}^  enucleated  rapidly,  without  regard 
to  the  vessels.  The  haemorrhage  is  often  considerable  for  a  few 
moments.  But  by  rapidly  removing  the  tumour  and  then 
drawing  forward  the  bottom  of  the  wound,  control  of  the  bleed- 
ing points  is  soon  obtained,  and  the  haemorrhage  arrested.  It 
should  be  borne  in  mind  that  if  the  tumour  to  be  enucleated  is 
very  large,  and  especially  if  it  be  solid,  a  very  considerable 
amount  of  blood  may  be  lost  in  a  very  few  minutes.  If  it 
seems  likely  that  an  enucleation  would  be  attended  with  great 
loss  of  blood,  it  may  be  better  to  perform  an  extirpation  rather 
than  to  attempt  enucleation.  With  regard  to  haemorrhage  in 
enucleation  operations,  Bruns,  speaking  of  200  enucleations 
performed  by  him,  says  that  "  in  seventy  per  cent,  the  bleeding 
was  unimportant,  in  twenty  per  cent,  considerable,  and  in  ten 
per  cent  really  profuse,  so  that  many  times  the  enucleation  had 
to  be  abandoned  altogether."  *  My  own  experience  of  enuclea- 
tion operations  is  more  favourable,  as  I  have  but  rarely  met 
with  haemorrhage  that  could  be  described  as  really  profuse.  I 
have  never  had  to  abandon  an  enucleation  on  account  of  haemor- 
rhage.    On  one  occasion  only  (in  1890)  did  I  begin  an  enucleation 

*    Verh.  (I.  (JeutscJi.  GeseUsch.  f.  C'liir.,  Berlin,  1896,  xxv.  pt.  ii.  p.  37. 


.SOO  THE    THYROID    GLAND. 

and  then,  finding  that  the  tumour  was  not  sufficiently  encapsuled, 
perform  an  extirpation  instead.  On  one  single  occasion  only 
have  I  had  to  pack  the  wound  with  gauze  on  account  of  htemor- 
rhage  and  this  was  one  of  niv  earlier  operations,  performed 
■when  I  had  had  but  little  practical  experience  ;  tlie  patient 
made  a  good  but  somewhat  tedious  recovery. 

Ha^morrhao;e  from  veins  is  )nore  to  be  feared  than  haemorrhage 
from  arteries.  The  former  are  often  greatly  dilated  and  their 
walls  may  be  so  thin  that  they  tear  very  readilv.  The  applica- 
tion, even  of  a  ligature,  may  sometimes  lead  to  the  vein  being- 
cut  through  by  it. 

A  Swiss  surgeon  has  related  to  me  that,  on  one  occasion, 
when  removing  a  deep-seated  goitre,  he  was  unfortunate  enough 
to  tear  a  large  hole  in  one  of  the  innominate  veins.  Blood 
poured  out,  the  haemorrhage  could  not  be  controlled,  and  the 
patient  died  on  the  table. 

Veins,  even  large  veins,  may  be  so  pressed  upon  bv  the  goitre 
that  they  are  emptied  of  their  blood.  They  may  then  resemble 
bits  of  fascia,  and  the  operator  may  easily  tear  them  across  if 
he  is  not  very  careful.  The  torn  end  of  a  vein  may  retract 
into  the  cellular  tissue  of  the  neck  or  mediastinum.  It  may 
then  be  very  difficult  to  secure  the  bleeding  vein.  The  blood 
extravasated  into  the  cellular  tissue  renders  recognition  of  the 
various  structures  difficult,  and  the  operator  may  be  seriously 
embarrassed.  Such  accidents,  however,  may  with  ordinary  care 
be  avoided. 

Primary  haemorrhage  in  a  goitre  operation  is  not,  at  the 
present  day,  very  greatly  to  be  feared,  provided  that  due  care 
be  taken  to  avoid  it.  At  the  same  time  it  must  be  remembered 
that  any  goitre  operation,  whether  extirpation  or  enucleation, 
if  carelessly  or  improperly  performed,  may  be  attended  by  great 
and  even  fatal  loss  of  blood. 

Injury  to  Werves. — Wound  of  the  recurrent  laryngeal 
nerve  is  an  important  and  serious  complication  of  the  operation 
of  extirpation,  although  it  cannot  occur  in  a  well  executed 
enucleation.  Although  I  have  never  yet  had  the  misfortune 
to  cut  this  nerve  in  any  operation  for  goitre,  yet  several  cases 
have  come  under  my  notice  in  which  the  nerve  has  been  cut  by 
others.     As  the  nerve  lies  in  contact  with  the  goitre  at  its  inner 


INJURY   TO   NERVES.  301 

and  back  part,  it  will  readily  be  understood  that  unless  con- 
siderable care  be  taken  when  dissectino-  in  this  region  section  of 
the  nerve  mav  easily  occur.  This  danger,  in  most  cases,  can, 
^nthout  difficulty,  be  avoided  by  keeping  close  to  the  surface 
of  the  goitre.  Sometimes  it  is  advisable  to  dissect  out  the  nerve 
and  hold  it  aside,  but  it  is  better,  if  possible,  not  to  expose  it 
at  all.  It  should  be  remembered  that  the  nerve  is  occasionally 
displaced  from  its  normal  groove  between  trachea  and  oesophagus, 
and  may  lie  spread  out  upon  the  posterior  surface  of  the  gland 
even  as  much  as  half  an  inch  outside  its  normal  position.  AMien 
in  this  abnormal  situation  it  runs  much  risk  of  being  wounded. 

Section  of  the  nerve  leads,  of  course,  to  paralysis  of  the 
coiTesponding  vocal  cord  and  consequent  alteration  of  voice. 

I  have  once  seen  an  mifortunate  patient  whose  recurrent 
nerves  had  been  wounded  on  both  sides  of  the  neck. 

The  patient  was  a  man  aged  32,  admitted  to  St.  Bartholomew's 
Hospital  on  account  of  severe  dyspncea.  Four  years  previously  a 
large  parenchymatous  goitre,  which  had  lasted  for  at  least  thirteen 
years,  had  been  removed  at  a  hospital  in  the  countr}-.  Dyspnoea 
and  dysphonia  were  the  immediate  result  of  the  operation.  The 
latter  was  permanent.  The  former  was  at  times  so  bad  that  even- 
tuallv  ti-acheotomy  was  performed.  Subsequently  the  larynx  was 
laid  open,  and  the  paralysed  vocal  cords  were  cut  away.  The 
wounds  were  then  alloAved  to  heal,  but  dyspnoea  again  returned, 
and  for  this  he  came  to  the  hospital.  Tracheotomy  was  again 
performed,  and  subsequently  all  the  old  scar  tissue  within  the 
lar^TTs  was  freely  removed,  after  the  latter  had  again  been  spHt 
open.  The  tracheotomy  tube  was  worn  for  sixteen  days,  and  then 
discontinued.  The  patient  made  a  good  recovery  from  this  opera- 
tion, and  left  the  hospital  six  weeks  later  with  a  false  glottis  of  fan 
size.* 

Short  of  actual  section  of  the  nerve,  it  may  be  damaged 
during  the  operation  by  undue  traction,  by  clamping  with 
forceps,  or  by  inclusion  in  a  ligature.  Washing  out  the  wound 
with  sti'ong  antiseptic  lotions  has  probably  in  some  cases  been 
the  cause  of  transient  paralysis  of  a  vocal  cord. 

*  St.  Bart.  Hos]).  Reps.  vol.  xxxiii. ,  1897.  p.  179.  I  •was  subsequently 
informed  that  shortly  after  leading  the  hospital  the  dyspnoea  returned  and 
tracheotomy  was  performed  for  the  third  time. 


302  THK    THYROID    GLAND. 

Wound  of  the  cervical  sympathetic  nerve  has  been  recorded 
a  few  times. 

It  is  most  likelv  to  occur  when  the  main  trunk  of  the  inferior 
thyroid  artery  is  being  tied. 

In  several  of  Rvdygier's  cases  (see  p.  242)  the  sympathetic 
was  injured. 

Wound  of  the  vagus  is  a  rare  accident.  Bramweil  *  records 
one  case  of  the  kind.  After  death  the  nerve  was  found  to  have 
been  included  in  a  ligature. 

Another  case  in  which  the  nerve  was  cut  occurred  at  a 
provincial  hospital  in  England  and  has  been  reported  privately 
to  me.     The  patient  died. 

Even  the  hypoglossal  nerve  has  been  wounded  on  at  least 
one  occasion. + 

Injury  to  the  trachea, — This  is  fortunately  a  rare  accident. 
Eiebrecht  records  four  cases  in  which  it  occurred.  A  fifth  case 
has  been  communicated  to  me  privately  by  a  surgeon  who  was 
present  at  the  operation.  A  considerable  portion  of  the  trachea 
was  removed  with  the  goitre.  The  patient  died  soon  afterwards. 
Berard^  mentions  another  case  which  occurred  to  Billroth. 
This  accident  can  scarcely  occur  except  from  gross  carelessness, 
or  from  Avant  of  knowledge  of  the  anatomy  of  the  parts. 

A  goitre  is  closely  connected  with  the  trachea  and  often  very 
firmly  adherent  to  it.  Frequently  a  careful  dissection  is  re- 
quired to  separate  these  structures.  Again,  the  trachea  is  often 
much  displaced,  and  msy  ne  more  or  less  surrounded  by  the 
goitre,  in  such  a  manner  that  the  operator,  if  inexperienced, 
may  suddenly  meet  with  the  trachea  quite  unexpectedly. 
If  the  goitre  be  hard  and  the  trachea  soft  and  flattened, 
wound  of  the  latter  may  thus  sometimes  occur. 

In  Guy's  Hospital  Museum  is  a  specimen  which  is  thus 
described  in  the  museum  catalogue ; 

No.  137. — A  trachea  with  an  enlarged  thyroid  gland,  of  Mhich 
the  right  lobe  has  been  removed  by  operation.  There  is  an  oval 
perforation  of  the  trachea  situated  one  and  a  half  inches  below  the 

*  Bvif.  Med.  Jour  It.  l!S8!i. 

t  Matas  alludes  to  a  case  in  which  this  accident  occurred.  Xew  OrlrcoiK 
Med.  and  Surg.  Jimni.  1889.  p.  68.5. 

J  ••Therapeuti(iue  Clm'urgicale  du  Goitre,"  Paris.  1897.  p.  22.5. 


INJURY   TO    NERVES.  303 

glottis^  which  "vvas  produced  by  the  pressure  of  the  end  of  a  clamp. 
Mary  W.,  cet.  17,  was  admitted  under  Mr.  H.,  for  an  enlarged 
th}Toid  gland.  The  right  lobe  Avas  removed,  and  a  clamp  applied 
to  the  pedicle.  The  patient  died  on  the  seventh  day  after  the 
operation,  from  acute  bronchitis. 

The  application  of  a  clamp  to  a  thyroid  pedicle  is  not, 
however,  to  be  recommended.  Berard*  mentions  a  curious  case 
of  Poncet's.  In  the  course  of  the  operation  tracheotomy  was 
performed  on  account  of  urgent  dyspnoea ;  the  canula  was 
pushed  through  the  posterior  wall  of  the  trachea  into  the 
oesophagus,  and  the  patient  succumbed. 

Injury  to  the  Pleura. — The  lower  horn  of  a  goitre  descending 
towards  the  thorax  is  frequently  in  contact  with  the  pleura. 
In  removing  this  part  of  a  goitre  it  is  possible  to  wound  the 
pleura.  This  serious  accident  is,  however,  not  likelv  to  occur 
unless  inflammation  or  malignant  disease  have  caused  adhesions. 

Liebrecht  records  an  early  case  of  Xussbaum's  in  which  one 
lobe  of  the  goitre  was  adherent  to  the  pleura.  In  effecting  its 
detachment  pneumothorax  was  produced  and  the  patient 
died. 

The  onlv  case  that  has  occurred  in  this  country,  so  far  as 
I  know,  is  an  unpublished  one,  of  which  notes  have  been  sent 
to  me  privately.  The  patient  died  very  soon  after  the  removal 
of  the  goitre,  and  at  the  autopsy  one  pleural  cavity  was  found 
to  be  full  of  air.  Doubtless  there  had  been  a  wound  of  the 
pleura,  although  my  informant  tells  me  that  the  actual  opening- 
was  not  detected. 

There  are  many  museum  specimens  of  malignant  disease  of 
the  thyroid  which  show  involvement  of  the  pleura  in  the  morbid 
groAAi:h. 

In  both  the  above-mentioned  cases  death  resulted  from  the 
pneumothorax  that  was  produced.  Yet  it  is  quite  possible  that 
a  wound  of  the  pleura  might  be  caused  and  the  patient  never- 
theless survive. 

Some  twenty  years  ago  I  was  myself  a  Avitness  of  a  puncture 
of  the  pleura  in  an  operation  for  ligature  of  the  subclavian 
artery.  Although  alarming  symptoms  at  once  manifested  them- 
selves, the  patient  nevertheless  eventually  recovered. 

*    Oj}.  rit.  p.  226. 


304  THE   THYROID    GLAND. 

Injury  to  the  Pharynx  and  (Esophagus. — Berard  *  nientions 
a  case  comnmnicated  by  Roux,  in  1894,  to  the  French 
Congress  of  Surcreons.  Old  infianimation  of  the  goitre  had  so 
altered  the  wall  of  the  pharynx  that  the  latter  was  accidentally 
opened. 

A  case  that  occurred  at  Charing  Cross  Hospital  a  few  years 
ago  was  that  of  a  hydatid  of  the  thyroid.  During  the  operation 
for  its  removal  the  oesophagus  was  opened.  The  wound  was 
sutured.     Both  these  patients  recovered. 

Collapse  of  the  trachea  is  a  serious  complication  that  occurs 
occasionally  in  very  bad  cases.  The  trachea,  which  has  been 
greatlv  flattened  and  has  lost  its  resiliency,  may,  after  removal 
of  the  goitre,  fail  to  expand.  Its  walls  become  sucked  together 
by  the  movements  of  respiration,  and  death  may  ensue  suddenly 
during  or  soon  after  the  operation.  This  complication  is 
fortunately  very  rare ;  in  most  cases  the  trachea  quickly  or 
gradually  expands  when  the  pressure  of  the  goitre  has  much 
removed.  Attempts  have  occasionally  been  made  to  separate 
the  flaccid  walls  of  the  trachea  by  passing  a  suture  through  its 
walls  on  either  side  and  tying  these  sutures  across  the  front  of 
the  trachea.  The  results  obtained,  however,  are  not  altogether 
satisfactorv  ;  it  may  be  necessary  to  perform  tracheotomy  if  the 
collapse  of  the  trachea  is  extreme  and  suffocation  is  imminent. 
Tracheotomy  should, however,  if  possible  be  avoided,  on  account 
of  the  grave  risk  of  sepsis  which  it  entails. 

II.  Complications  occurring  shortly  after  the 
Operation. 

Secondary  hsemorrhage,  once  a  serious  danger  of  thyroid 
operations,  has  now,  since  the  introduction  of  aseptic  methods 
of  treating  wounds,  become  almost  a  thing  of  the  past. 
Liebrecht,  writing  of  the  operations  performed  before  1883, 
mentions  no  less  than  thirty-one  cases  in  which  this  serious 
complication  occurred.  At  the  present  time  it  is  to  be  feared 
only  in  some  few  cases  of  operation  for  malignant  disease  of  the 
thyroid,  for  suppurating  goitre  and  in  the  rare  cases  in  which 
serious  sepsis  follows  extirpation  of  an  innocent  goitre. 

I  have  never  seen  secondary  haemorrhage  after  any  thyroid 
operation. 

*   Oj),  fit.  p.  238, 


COMPLICATIONS   AFTER   OPERATION.  305 

Becurrent  haemorrhage  is,  however,  a  real  and  sonietinies  a 
serious  danger.  From  an  artery  it  is  rare,  although  it  may 
sometimes  occur  from  the  slipping  of  a  ligature  which  has  been 
insecurely  applied. 

It  need  scarcely  be  said  that  the  greatest  care  should  always 
be  taken  to  tie  all  the  arteries  firmly  and  with  a  sufficiently 
stout  ligature. 

Recurrent  haemorrhage  from  Aeins  is  more  common  than  from 
arteries,  because  it  is  more  easy  at  the  time  of  operation  to 
overlook  a  wound  of  a  vein  than  one  of  an  artery. 

It  is  especially  after  enucleations  that  recurrent  haemorrhage 
is  apt  to  occur.  A  wounded  vein  may,  while  the  patient  is 
under  the  anaesthetic,  give  rise  to  no  hsemorrhage.  But  sub- 
sequently, especially  during  the  coughing  or  vomiting  that  may 
follow  the  operation,  the  temporarily  closed  mouth  of  the  vein 
may  re-open  and  allow  of  serious  haemorrhage. 

Troublesome  recurrent  haemorrhage  may  occur,  too,  in  the 
form  of  a  general  oozino-  from  numerous  small  vessels. 

It  has  already  been  mentioned  that  it  is  of  the  utmost  import- 
ance to  see  that  all  bleeding  has  been  completely  arrested  before 
the  wound  is  closed. 

Sometimes,  especially  after  enucleation  of  a  large  goitre,  it 
is  well  to  let  the  patient  recover  partially  from  the  anaesthetic 
before  the  wound  is  closed.  The  straining  that  attends  efforts 
at  vomiting  thus  tests  the  efficiency  of  the  haemostasis. 

Some  years  ago  I  was  watching  the  performance  of  a  large 
goitre  operation.  The  operation  had  been  successfully  accom- 
plished, all  bleeding  had  apparently  been  arrested,  and  the  last 
sutures  were  being  inserted.  The  patient  then  began  to  retch. 
Suddenly  blood  poured  out  from  between  the  stitches  all  along 
the  wound.  This  was  rapidly  opened,  and  it  was  then  found 
that  a  large  vein  at  the  root  of  the  neck  had  escaped  ligature. 
Until  the  patient  began  to  retch  it  had  lain  collapsed  and  did 
not  bleed.  The  vein  was  tied,  and  no  harm  ensued.  But  had 
this  accident  occurred  an  hour  or  two  later,  after  the  patient 
had  returned  to  bed,  the  result  might  have  been  very  different. 

Dr.  A.  H.  Corley*  has  recorded  in  full  an  interesting  case  of 
a  very  large  thyroid  tumour  removed  by  "  rapid  enucleation 

*   Trail-:.  Bdjj.  Acad,  of  Med.  in  Ireland,  Dublin,  1889,  vii.  169-175. 

U 


306  thp:  thyroid  gland. 

with  the  finger  and  director."  After  the  sutures  had  been 
inserted,  and  the  patient  was  about  to  be  transferred  to  bed, 
"  a  sudden,  most  alarming  gush  of  hftmorrhage  took  place ; 
the  blood  welled  up  in  dark  streams  between  all  the  points  of 
suture,  the  patient's  face  blanching  and  his  pulse  becoming 
feeble."'  The  sutures  were  immediately  cut  and  pressure  applied 
to  the  interior  of  the  wound  by  means  of  sponges.  After  in- 
effectual attempts  had  been  made  to  secure  the  bleeding  vessel 
or  vessels  with  ligatures,  it  was  decided  to  plug  the  wound  with 
gauze  and  wool.  The  plugs  were  left  in  for  several  days,  and 
the  wound  healed  eventually  by  granulation. 

If  the  wound  has  to  be  opened  up  some  hours  after  the 
operation,  it  is  frequently  a  matter  of  the  greatest  difficulty  to 
find  the  bleeding  point.  The  tissues  are  so  infiltrated  with 
blood  that  the  actual  bleeding  point  or  points  cannot  be  seen. 
Under  these  circumstances  it  is  generally  best  to  pack  the 
wound  with  gauze. 

Recurrent  haemorrhage  is  dangerous  not  only  on  account  of 
the  loss  of  blood  which  it  occasions.  By  filling  up  the  cavity 
previously  occupied  by  the  goitre,  the  blood  may  press  most 
injuriously  upon  the  trachea  and  set  up  serious,  or  even  fatal, 
dyspnoea. 

]\lr.  Stanley  Boyd  has  been  kind  enough  to  give  me  the 
following  details  of  a  case  that  occurred  at  Charing  Cross 
Hospital : 

A  young  woman  had  an  adenoma  of  the  th3-roid.  The  tumour 
was  removed  by  operation  without  any  difficulty.  Bleeding  was  not 
excessive^  and  was  easily  controlled.  The  wound  was  sewn  up 
without  drainage.  A  few  hours  after  the  operation  an  urgent 
message  was  received  from  the  house  surgeon,  saying  that  the 
patient  had  severe  dyspnoea.  The  patient  was  found  to  be  livid, 
and  in  great  distress.  The  stitches  were  at  once  removed  and  the 
whole  wound  opened  up.  A  handful  of  blood  clot  w^as  taken  away, 
and  the  dyspnoea  immediately  relieved.  Considerable  oozing  of 
blood  was  found  to  be  still  going  on,  and  could  not  be  controlled 
by  ligature.  Eventually  the  bleeding  was  arrested  by  plugging, 
and  the  patient  made  a  good  recovery.* 

*  See  aho  a  somewhat  similar  case  described  iu  my  Lectm-es  at  the  Eoj'al 
College  of  Surgeon.*,  Brit.  Med.  Juurn..  June  1890. 


COMPLICATIONS   AFTER   OPERATION.  307 

An  almost  identical  case  came  under  my  notice  when  Surgical 
Registrar  at  St.  Bartholomew's  Hospital. 

Sepsis. — It  is  of  the  utmost  importance  that  the  wound 
produced  by  a  goitre  operation  should  heal  by  primary  vmion. 
The  greatest  care  should  therefore  be  taken  to  maintain  the 
strictest  asepsis  throughout.  It  is  mainly  owing  to  great  im- 
provements in  the  aseptic  details  of  the  operation  now  performed, 
that  the  removal  of  a  goitre  at  the  present  day  is  no  longer  as 
dangerous  as  it  used  to  be  twenty  or  thirty  years  ago.  Indeed, 
the  danger  from  sepsis  is  now  so  slight  that  serious  complications 
due  to  this  cause  are  very  rarely  seen.  Out  of  the  126  opera- 
tions for  the  removal  of  goitre  that  it  has  fallen  to  my  lot  to 
perform,  there  has  not  been  one  in  which  I  have  lost  a  patient 
from  any  kind  of  sepsis.  Occasionally  a  mild  amount  of  sepsis 
has  occurred,  and  has  been  sufficient  to  prevent  primary  union 
of  the  wound.  Very  rarely,  indeed,  has  the  sepsis  been  sufficiently 
marked  to  cause  any  real  anxiety  on  this  score.  Reference  to 
the  table  of  cases  in  the  Appendix  will  show  that  in  the  last 
hundred  operations  primary  union  took  place  in  91  cases. 

The  extensive  involvement  of  the  cellular  tissue  of  the  neck 
in  the  operation  of  extirpation  renders  sepsis,  should  it  unfortu- 
nately occur  in  this  tissue,  a  matter  of  grave  danger.  The 
serious  nature  of  cellulitis  at  the  root  of  the  neck  and  in  the 
mediastinum  is  well  known.  Such  cellulitis  is  the  more  to  be 
dreaded,  as  it  is  very  insidious  in  its  onset  and  consequently 
its  existence  is  apt  to  be  overlooked  in  its  earliest  stages.  There 
may  be  very  little  elevation  of  temperature,  and  acute  symptoms 
of  inflammation  may  be  conspicuous  by  their  absence.  A  per- 
sistently rapid  pulse  may  be  the  most  important  early  symptom. 
Later,  pleural  friction,  cough,  and  other  signs  of  septic  trouble 
in  the  chest  may  render  the  diagnosis  only  too  clear ;  but  at 
this  period  treatment  is  usually  of  but-  little  use  in  stopping 
the  progress  of  this  very  fatal  complication. 

If,  shortly  after  the  performance  of  an  extirpation  or  an 
enucleation  of  a  goitre,  decided  symptoms  of  sepsis  occur,  the 
wound  should  at  once  be  thoroughly  opened  up.  Strips  of 
antiseptic  gauze  should  be  laid  in  it  and  the  wound  treated  as 
an  open  one,  all  attempts  to  procure  primary  union  being 
abandoned. 


308  THE   THYROID    GLAND. 

The  most  troublesome  case  of  a  sinus  that  has  occurred  in 
mv  own  practice  is  that  recorded  in  the  table  on  p.  350  (case  97). 

Tlie  patient  was  a  lady,  aged  28,  upon  whom  I  had  to  perform 
a  double  enucleation.  The  tumours  were  solid  and  very  deeply 
seated  on  either  side  of  the  trachea,  and  behind  the  sternum. 
They  caused  a  good  deal  of  respiratory  trouble.  The  operation 
presented  no  special  difficulty,  and  was  performed  in  the  usual 
manner.  The  w^ound  was  sewn  up  and  a  small  drain  inserted  into 
the  superficial  part  of  it  through  a  separate  opening  in  the  skin. 
The  drain  was  removed  on  the  day  after  the  operation.  The 
condition  of  the  patient  in  the  next  five  days  was  not  altogether 
satisfactory.  On  two  occasions  during  this  period  the  temperatui-e 
was  a  little  over  lOO""  (lOC^""  and  100.2").  During  the  same  period 
the  pulse  was  almost  constantly  a  little  over  100.  On  the  sixth  day 
after  the  operation  the  temperature  suddenly  rose  to  102.2,  the 
pulse  rate  being  118.  The  wound  was  then  immediately  opened 
up  to  a  certain  extent,  but  as  it  seemed  healthy  and  contained 
little  or  no  fluid,  the  deeper  parts  were  not  disturbed.  Wet  dress- 
ings of  perchloride  of  mercury  were  applied,  and  the  temperature 
and  pulse  rapidl)'  subsided.  Two  days  later  the  temperature  was 
normal,  and  it  never  afterwards  rose  above  the  normal.  Three 
weeks  after  the  operation  the  patient  went  back  to  her  home  in 
the  country ;  she  was  in  good  health,  but  a  small  sinus  was  still 
present,  which  appeared  to  be  on  the  point  of  healing.  It  did  not 
heal,  however ;  silk  ligatures  from  time  to  time  came  away,  and 
there  was  constantly  a  small  amount  of  discharge  from  the  sinus. 
Three  months  after  the  first  operation,  the  sinus  was  opened  up 
again,  and  found  to  extend  to  a  depth  of  nearly  an  inch  on  either 
side. 

During  this  time  the  patient  was  not  confined  to  bed  or  even  to 
the  house  ;  she  went  about  as  usual,  or  rather,  far  more  than  she 
had  been  accustomed  to  do  before  the  goitre  was  removed.  She 
was  able  to  ride,  play  lawn  tennis,  and  take  active  exercise  of  all 
kinds.  After  the  second  operation  the  left  portion  of  the  sinus 
healed  up,  and  never  afterwards  gave  any  further  trouble.  The 
pocket,  however,  that  led  towards  the  right  lobe  of  the  gland  still 
refused  to  heal.  The  patient  was  very  averse  to  a  further  operation, 
especially  as  the  sinus  appeai*ed  to  be  almost  healed.  She  then 
went  abroad  for  several  weeks,  the  sinus  being  dressed  and  plugged 
with  gauze  every  day.  Finally,  seven  months  after  the  original 
operation,  the  sinus  was  again  opened  up.  It  was  plugged  with 
gauze  and  dressed  twice  a  day,  and  at  the  end  of  four  weeks  it  was 


COMPLICATIONS   AFTER   OPERATION.  309 

at  last  soundly  healed.  Much  of  the  trouble  in  this  case  was  due 
to  the  fact  that  the  patient  was  exceedingly  anxious  about  her  scar^ 
which  had  been  placed  transversely  at  the  root  of  the  neck^  and 
was  but  little  over  two  inches  in  length.  Neither  of  the  three 
secondary  opei*ations  involved  any  of  the  surrounding  skin.  Had 
the  whole  wound  been  freely  opened  at  an  early  stage  without  any 
regard  to  the  situation  or  extent  of  the  scar,  no  doubt  healing 
would  soon  have  taken  place.  As  it  was,  the  patient  was  eventually 
left  with  a  short  and  not  very  wide  scar,  but  at  the  cost  of  a  con- 
siderable amount  of  time  and  trouble. 

Deep-seated  suppuration  in  the  neck  is  extremely  likely  to 
extend  to  the  thorax  and  cause  fatal  mediastinitis.  In  some 
cases  the  pus  makes  its  wa}'  into  the  trachea  or  oesophagus. 
The  following*  is  an  example  of  such  a  case.  It  occurred  at 
St.  Bartholomew''s  Hospital  in  1886,  and  is  the  only  example 
that  I  have  myself  witnessed  of  a  death  due  directly  to  sepsis 
after  removal  of  a  goitre.  It  is  a  very  good  illustration  of 
what  may  happen  when  this  operation  is  performed  without 
antiseptic  precautions. 

Edward  B.,  cet.  41,  was  admitted  into  St.  Bartholomew's  Hospital 
under  the  care  of  Sir  William  Savory  on  account  of  a  goitre  that  he 
had  had  for  some  four  years.  The  tumour,  which  was  partly  cystic 
and  partly  solid,  was  situated  unusually  high  up  on  the  right  side 
of  the  neck.  (It  is  depicted  in  Fig.  41.)  It  had  been  tapped  on 
more  than  one  occasion. 

On  October  l6,  1886,  the  tumour  was  removed  by  Sir  William 
Savory.  A  portion,  which  was  thought  to  be  adherent  to  the  great 
vessels  of  the  neck  was  left  behind.  '•  A  plug  of  dry  unsterilised 
lint  was  placed  in  the  cavity  and  the  Avouud  stitched  up,  except  at 
its  lowest  part,  and  dressed  with  carbolic  oil  lint.  " 

The  opei'ation  was  followed  immediately  by  a  rise  of  temperature 
to  102'.  On  October  18  the  plug  of  lint  \%as  removed.  The 
temperature  remained  at  about  102^  until  October  21,  when  it 
began  to  fall,  and  it  became  normal  on  the  24th.  The  patient  was 
thought  to  be  doing  well  until  November  2,  when  his  "  tempera- 
ture began  to  rise  again,  and  loss  of  appetite,  sleeplessness,  furred 
tongue,  pain  in  the  wound  and  right  side  of  the  neck,  and  slight 
difficulty  of  swallowing  ensued.      On  the  4th  of  November  these 

*  This  case  has  been  published  iu  full  by  Mr.  C.  A.  Parker  iu  St.  Bart.  Hosp. 
Reps..  18<S7,  xxiii.  p.  218.  The  particulars  giveu  above  are  taJsen  pai'tly  fi-om 
liis  and  partly  from  my  own  notes. 


310  THE   THYROID    GLAND. 

symptoms  had  increased  in  severity,  and  there  was  a  good  deal  of 
heat,  redness  and  swelling  about  the  wound  and  extending  across 
the  middle  line  to  the  left  side  of  the  neck.  The  wound  was 
slightly  enlarged  and  examined  with  a  probe,  but  no  collection  of 
pus  could  be  found.  .  .  .  On  November  6  the  temperature  was 
102.8,  and  a  cough  Avith  pneumonic  expectoration  made  its  appear- 
ance. On  examination  impairment  of  resonance  at  both  bases,  with 
fine  crepitations,  was  found.  The  swelling  of  the  neck  and  difficulty 
of  deglutition  having  much  increased,  the  patient  was  anaesthetised 
and  the  wound  freely  reopened.  No  collection  of  pus  was  dis- 
covered. A  long  incision  was  also  made  in  the  middle  line  to 
relieve  tension.  .  .  .  By  November  1 1  the  swelling  and  inflam- 
mation of  the  neck  had  almost  entirely  subsided,  and  the  wounds 
looked  perfectly  healthy.  The  temperature,  however,  had  risen 
again  to  102.6^,  and  the  patient's  general  condition  was  decidedly 
worse.  He  was  very  weak  and  prosti'ate.  His  cough  got  more 
ti'oublesome,  and  was  accompanied  by  an  abundant  and  offensive 
expectoration.  Pulse  weak,  112."  On  November  l6  it  was 
noticed  that  air  was  passing  in  and  out  of  the  wound.  Next  day 
the  patient  had  a  severe  rigor  and  a  temperature  of  lOJ^.S'.  He 
gradually  became  weaker  and  weaker,  and  died  on  November  19. 

The  post  mortem  showed  a  minute  opening  between  the  unhealed 
portion  of  the  wound  and  the  interior  of  the  trachea.  This  opening 
Avas  between  the  second  and  third  rings.*  There  was  pneumonia 
of  both  lungs,  with  pus  in  the  tubes  and  a  gangrenous  condition  of 
a  small  portion  of  the  right  base. 

Rapid  Pulse  and  Restlessness. — A  very  serious  complication, 
which  is  fortunately  rare,  is  characterised  by  two  prominent 
symptoms  :  restlessness  and  great  rapidity  of  the  pulse. 

Very  soon  after  the  operation  the  pulse  is  noticed  to  be  rapid. 
It  rises  quickly  to  150  or  even  200,  and  then  becomes  so  feeble 
that  it  cannot  be  counted.  At  the  same  time  the  patient  is 
very  restless  and  excitable.  Death  may  occur  within  a  few 
hours,  or  at  most  a  day  or  two. 

Post  mortem  little  or  nothing  may  be  found  to  account  for 
the  death. 

I  have  never  met  with  this  fatal  complication  in  mv  own 
practice,  and  have  seen  but  little  of  it  in  the  practice  of  others. 
Occasionally  a  minor  degree  of  restlessness  and  a  pulse  of  130 

*  The  specimen  is  now  in  St.  Bai't.  Hosp.  Miis.  No.  2319D. 


COMPLICATIONS   AFTER   OPERATION.  311 

or  130  in  cases  of  my  own  have  caused  me  some  little  anxiety 
for  a  few  hours  or  even  a  dav  or  two. 

The  following  case  is  one  that  I  witnessed  in  St.  Bartholomew''s 
Hospital  in  1889 : 

A  young  man  was  admitted  to  the  hospital  on  accomit  of  an 
mnocent  tumom-  of  the  left  lobe  of  the  thyroid.  It  was  about  as 
large  as  an  orange.  It  had  caused  some  trouble  in  respiration^  and 
had  caused  paralysis  of  one  vocal  cord. 

The  left  lobe  was  removed  by  extirpation,  and  the  wound  washed 
out  with  carbolic  acid  lotion.  The  operation  presented  no  especial 
difficulty,  and  was  not  an  unusually  long  one.  Immediately  after  the 
operation,  the  patient's  condition  was  good.  But  veiy  soon  the 
pulse  became  very  rapid,  and  the  patient  showed  great  restlessness. 
The  rapiditv  of  the  pulse  increased  quickly  until  it  was  over  200, 
and  could  scarcelv  be  felt.  This  continued  until  the  patient  died 
on  the  second  day  after  the  operation. 

At  the  post-mortem  examination,  which  was  performed  by  Mr. 
Bowlby,  nothing  of  importance  was  discovered.  The  wound  had 
nearly  healed  by  first  intention.  No  nerves  of  importance  had 
been  cut,  nor  was  there  any  obvious  bruising  of  them.  The  vagus 
nerve  was  carefully  exammed  and  found  intact.  There  was  no 
evidence  of  septictemia.  The  tumour  *  that  was  removed  consisted 
of  a  number  of  adenomata,  some  of  which  were  solid  while  others 
had  undergone  cystic  degeneration. 

Dr.  Rodocanachi  has  published  in  fuU^^  an  interesting  case 
of  a  similar  nature  which  occurred  in  University  College  Hospital 
durine:  his  house-surg-eoncv  there.  The  followino-  is  an  abstract 
of  his  report : 

A  married  woman,  aged  49,  was  admitted  to  the  hospital  on 
February-  20,  1896,  on  account  of  a  very  large  cystic  goitre,  in- 
volving both  lobes  of  the  gland,  and  causing  serious  dyspnoea  from 
pressure  on  the  trachea.  When  the  patient  was  quiet  the  pulse 
was  ll6  and  the  respiration  40  per  minute.  On  the  day  after 
admission  "  the  right  lobe  of  the  gland,  which  was  the  larger,  was 
dissected  out  through  a  free  incision,  aU  the  vessels  being  clamped 
before   they  were  cut.      A   cyst   on  the  left   side  was   aftei-Avards 

*  St.  Bart.  Hosp.  :\Ius.  Xo.  2.31UD. 

t  "  On; Four  Cases  of  Goitre  Treated  by  Operation  and  Certain  Dangerous 
Sj-mptoms  which  may  follow  the  Operation."  by  A.  .J.  Eodocanachi,  il.D., 
Lancet,  1897,  ii.  911. 


312  THK   THYROID    GLAND. 

enucleated,  but  it  was  ru])tiired  during  removal,  and  a  good  deal  of 
the  pale  brown  contents  necessarily  escajjed  into  the  wound.  No 
irrigation  was  employed,  but  the  wound  was  closed,  a  small  drainage 
tube  being  inserted  in  the  lower  end."  After  the  operation,  which 
appears  to  have  been  uncomplicated,  the  patient's  condition  seemed 
to  be  quite  satisfactory.  She  was  quiet  and  comfortable,  and 
continued  to  be  so  until  about  ten  hours  after  the  operation,  when 
"  suddenly  her  symptoms  changed  completely.  She  became  ex- 
tremely restless,  tossing  herself  about  in  bed.  This  was  the  most 
striking  symptom,  as  previously  she  had  been  a  most  tractable 
patient.  The  pulse  ran  up  to  about  1 80  ;  the  respiration  became 
very  rapid,  from  50  to  60,  and  shallow,  but  not  embarrassed  ;  there 
was  no  stridor.  The  temperature  was  found  to  be  99-2.  Whereas 
previously  she  had  been  hopeful,  she  now  declared  that  she  was 
about  to  die."  Although  a  little  quieter  after  a  hypodermic  injec- 
tion of  morphia,  the  symptoms  soon  returned  in  all  their  intensity, 
and  death  occurred  some  fifteen  hours  after  the  operation. 

The  post-mortem  examination  showed  but  little.  The  tumour 
removed  seems  to  have  been  an  ordinary  pai-enchymatous  one,  with 
numerous  small  cysts  and  much  fibrous  tissue,  as  might  have  been 
expected  in  a  woman  of  her  age.  The  remaining  portion  of  the 
gland  Avas  exactly  similar.  A  careful  dissection  of  the  neck  showed 
that  there  had  been  no  damage  to  any  of  the  main  nenes.  There 
appears  to  have  been  no  evidence  of  sejiticgemia,  and  it  was  clear 
that  the  death  was  not  due  to  haemorrhage. 

Mr.  F.  T.  Paul*  of  Liverpool  has  recorded  a  somewhat  similar 
case : 

The  patient  was  a  girl  aged  15,  with  a  rather  large  ^^Hrenchy- 
matous  goitre.  The  tumour  was  soft,  and  did  not  pulsate ;  it 
involved  both  lobes  about  equally.  The  heart  was  excitable,  the 
impulse  diffused,  and  there  Avas  a  soft  systolic  bruit  at  the  apex. 
The  patient  appeared  to  be  quite  strong  enough  to  bear  a  serious 
operation.  The  left  lobe  and  isthmus  of  the  thyroid  gland  wei'e 
removed.  "^The  operation  was  perfectly  straightforward,  and  the 
patient  left  the  theatre  in  excellent  condition.  All  details  as  to 
dressings,  drainage,  &c.,  were  carried  out  in  the  usual  manner. 
During  the  night  she  became  restless  and  uneasy,  an  irritable  cough 
set  in,  Avith  a  mucous  rattle  in  the  throat.  The  temperature  Avas 
100',  the  pulse  130,  and  the  respiration  26  and  laboured.  On  the 
morning  after  the  operation  the  same  condition  AAas  present ;  the 

*  "A  Fatal  Case  of  Th^Toidectouiy.""  Brit.  Med.  Juiirn.,  .Jau.  1.  1898.  p.  17. 


COMPLICATIONS   AFTER   OPERATION.  313 

wound  was  dressed  and  appeared  perfectly  healthy.  In  the  after- 
noon the  temperature  rose  to  103,  and  fearing  that  the  ether 
inhalation  had  set  up  ether  bronchitis,  steam  and  eucalyptus  vapour 
were  used,  with  stimulants  and  extra  nourishment.  Subsequently 
the  restlessness,  anxiety,  distressed  breathing,  and  frequency  of  the 
pulse  increased,  and  the  temperature  was  generally  between  101^ 
and  102'  F.  There  was  no  further  evidence  o1  bronchitis  .  .  . 
the  Graves's  disease-like  symptoms  increased  in  severity,  the  pulse 
became  uncountable,  and  the  patient  died  just  two  and  a  half  days 
after  the  operation." 

A  post-mortem  examination  showed  the  following  :  '•  In  regard 
to  the  wound,  there  was  a  want  of  healing  action,  and  the  fluid 
contained  in  it  was  of  a  very  wateiy  character,  but  there  was 
nothing  suggestive  of  septic  changes.  The  divided  surface  of  the 
thyroid  looked  quite  fresh,  as  though  repair  had  not  yet  commenced. 
The  bases  of  the  lungs  were  congested,  an-]  there  was  a  little 
tenacious  mucus  in  some  of  the  tubes,  but  no  general  bronchitis. 
The  heart  and  all  the  other  internal  organs  were  healthy,  except 
the  livei'j  which  was  very  fatty  and  perfectly  nodulous  throughout 
from  idiopathic  cirrhosis." 

In  St.  Thomas's  Hospital  Reports  i-s  an  account  of  another  fatal 
case  in  which  the  operation  was  excision  of  the  isthmus  only  of 
a  large  parenchvmatous  goitre.  The  patient  was  a  woman  aged 
33.  Before  the  operation  the  pulse  was  108.  Double  ligatures 
were  applied  to  the  isthmus  before  its  removal.  The  wound 
was  drained.  The  patient  was  extremely  restless  after  the 
operation  and  was  little  relieved  by  morphia.  The  pulse  was 
verv  rapid,  reaching  160,  and  nine  hours  after  the  operation 
the  patient  died  suddenly. 

In  St.  Bartholomew's  Hospital,  in  1899,  the  same  group  of 
symptoms — restlessness  and  rapid  pulse — set  in  after  division  of 
the  sympathetic  nerve  on  both  sides  of  the  neck.  The  patient  Avas 
a  voung  woman  with  well-marked  symptoms  of  Graves's  disease. 
In  this  case  the  temperature  also  rose  to  a  great  height  (105-6'), 
and  the  patient  died  a  few  hours  after  the  operation. 

Instances  in  which  similar  fatal  symptoms  have  occurred  after 
operations  upon  the  thyroid  gland  in  Graves's  disease  are  too 
well  known  to  require  detailed  notes  of  cases. 

Sometimes  severe  symptoms  have  followed  operations  both 
upon  exophthalmic  and  simple  forms  of  goitre,  but  have  subsided 


314  THE    THYROID    GLAND. 

after  a  short  time,  and  the  patients  have  recovered.  Rodocanachi  * 
reports  the  case  of 

a  woman  aged  35,  from  whom  a  thyroid  cyst  was  removed^  the 
cyst  being  ruptured  in  the  course  of  the  ojieration.  Thirty  hours 
later  the  temperature^  pulse^  and  respiration  were  respective!}' 
101.3"^  136^  and  36,  and  there  was  much  restlessness.  The  symp- 
toms all  subsided  after  a  dose  of  morphia,  and  the  patient  made  a 
good  recovery. 

Fault  also  narrates  a  case  in  which  he  operated  for  chronic 
Graves's  disease,  removing  one  half  of  the  gland  : 

The  patient  was  a  woman  aged  43.  When  the  pulse  and  tem- 
perature began  to  rise  and  restlessness  set  in^  the  wound  was 
freely  opened  up  and  packed  with  salicylic  wool.  Nevertheless, 
the  temperature  subsequently  rose  to  104.8  ,  the  pulse  became 
almost  uncountable,  and  the  respirations  Avere  36.  There  was  in 
this  case  a  profuse  discharge  of  watery  secretion  from  the  wound . 
The  packing  in  the  wound  was  frequently  changed — about  every 
two  hours — and  by  the  fourth  day  after  the  operation  all  alarming 
symptoms  had  subsided. 

The  cause  of  the  alarming  group  of  symptoms  in  these  and 
similar  cases  is  not  altogether  clear.  That  such  symptoms  are 
sometimes  due  to  sepsis  there  can  be  no  doubt.  It  must  be 
remembered  that  sepsis  may  occur  and  rapidly  prove  fatal 
without  causino-  anv  verv  obvious  chang-es  that  can  be  detected 
post  mortem. 

Bacteriological  examination  alone  may  afford  the  necessary 
proof  of  sepsis,  but  sepsis  will  certainly  not  account  for  the 
symptoms  in  a  great  many  of  the  cases. 

It  has  been  supposed  by  some  that  they  are  due  to  athyroid- 
ism.  Bat  if  this  were  the  true  explanation  we  should  expect 
to  find  these  symptoms  more  common  than  they  are  in  cases 
where  large  portions  of  both  lobes  have  been  removed,  as  for 
example  in  cases  of  double  resection.  It  is  difficult,  also,  on 
this  supposition  to  explain  their  occurrence  after  comparatively 
small  operations  like  division  of  the  sympathetic  nerves  and 
resection  of  the  isthmus. 

A  more  probable  supposition  is  that  they  are  due  to  hyper- 

*    Oj).  rit.  J    Op.  rit. 


COMPLICATIONS    AFTER    OPERATION.  315 

thvroidism.  that  is,  to  sudden  absorption  of  a  large  quantitv  of 
thyroid  secretion. 

This  is  the  view  taken  bv  Rodocanachi  and  Paul  in  their 
excellent  papers  upon  the  subject.  This  absorption  niav  be 
caused  bv  prolonged  and  rough  manipulation  of  the  gland 
during  the  operation,  whereby  the  colloid  is  sc[ueezed  into  the 
lymphatics.  Or  possibly  it  may  be  caused  by  the  exudation  of 
colloid  into  the  wound  from  the  cut  surface  of  the  gland. 

To  the  theory  of  hyperthyroidism,  however,  it  may  be 
objected  that  the  same  group  of  symptoms  may  supervene 
after  operation  upon  tumours  by  no  means  very  full  of  secretion 
— e.g.,  old  fibrous  goitres  and  malignant  tumours.  Further  it 
would  not  account  for  their  occurrence  after  division  of  the 
sympathetic,  or  ligature  and  resection  of  the  isthmus.  If 
secretion  from  the  cut  surface  of  the  gland  into  the  wound 
were  the  cause,  then  drainage  would  surely  suffice  to  prevent 
their  occurrence.  But  in  some  of  the  recorded  cases  drainage 
has  been  employed  throughout,  and  yet  this  complication  set  in. 

Ao-ain,  I  find  it  difficult  to  understand  why  I  have  never 
witnessed  this  complication  in  the  numerous  cases  of  my  own 
in  which  I  have  removed  large  parenchymatous  goitres  without 
any  ligature  of  the  isthmus.  I  have  seldom  tied  the  isthmus 
en  masse.  Indeed,  in  verv  many  cases  where  the  isthmus  is 
thick,  measuring  two  or  more  inches  in  diameter,  it  is  quite 
impossible  to  place  such  a  ligature  satisfactorily  upon  it. 

The  question  mav  be  raised  whether  the  rapid  action  of  the 
heart  mav  not  be  caused  by  some  irritation  of  or  inj  ury  to  the 
cervical  cardiac  nerves. 

It  is  at  least  conceivable  that  such  injury  might  be  caused 
either  bv  rough  manipulation,  by  sepsis,  or  by  irritating  anti- 
septic lotions.  It  seems  clear  that  the  use  of  antiseptic  lotions 
in  operations  upon  exophthalmic  goitre  has  a  marked  tendency 
to  produce  these  dangerous  symptoms. 

Against  this  cardiac  nerve  theory  must  be  placed  the  undoubted 
fact  that  these  symptoms  are  far  more  likely  to  follow  operations 
upon  the  th\Toid  gland  than  those  performed  upon  other  tumours 
at  the  root  of  the  neck. 

It  is,  perhaps,  best  to  admit  that  the  exact  cause  of  this 
group  of  unpleasant  symptoms  Is  not  yet  thoroughly  understood. 


:n6  THE   THYROID   GLAND. 

The  theory  of  hyperthyroidism,  tempting  as  it  is,  can  hardly  be 
considered  as  proved. 

It  is  well,  however,  as  a  matter  of  practical  importance,  to 
bear  in  mind  that  restlessness  and  extreme  rapidity  of  pulse  are 
more  likely  to  follow  operations  upon  the  goitre  of  Graves's 
disease  than  upon  any  other  kind  of  goitre ;  that  they  are  by 
no  means  unknown  in  operations  upon  parenchymatous  goitre, 
and  that  they  may  even  occur  in  other  thyroid  operations. 
They  can  best  be  avoided  by  taking  care  to  handle  the  gland 
as  gently  as  possible,  and  b?j  exei-cisiiig  the  most  rigid  asepsis  in 
the  perjbrmance  (rfthe  operations. 

Drainage  of  the  wound  is  probably  advisable  in  cases  where 
the  supervention  of  these  symptoms  seems  likely. 

Patients  who  have  a  somewhat  rapid  pulse  before  the  operation 
are  those  in  whom  the  symptoms  are  most  likely  to  occur. 

In  uiy  own  practice  I  am  in  the  habit  of  giving  three  grains 
of  quinine  every  four  or  six  hours  in  every  case  in  which,  after 
a  goitre  operation,  the  pulse  or  temperature  reaches  100.  If 
the  patient  shows  any  sign  of  restlessness,  a  moderately  large 
dose  of  morphia  is  given  at  once. 

Whether  this  treatment  is  really  efficacious  in  warding  off 
further  development  of  these  dangerous  symptoms,  whether 
their  absence  is  due  to  the  technique  employed  at  the  operations, 
or  whether  it  is  simply  that  I  have  been  more  fortunate  than 
some  other  surgeons  in  not  having  yet  lost  a  patient  from  this  cause, 
are  points  upon  which  I  hesitate  to  express  a  definite  opinion. 

Compression  of  Recurrent  Laryngeal  Nerve  by  Scar. — As 
the  wound  heals,  it  will  occasionally  be  found,  after  extirpation, 
that  paralysis  of  a  vocal  cord  ensues. 

This  late  paralysis  is  especially  apt  to  occur  in  cases  in  which 
the  nerve  has  been  exposed  or  dissected  out  in  the  course  of  the 
operation.  It  is  due  to  involvement  of  the  nerve  in  the  deeper 
portions  of  the  scar. 

Tetany  is  a  serious  complication  which  has  (been  recorded 
many  times,  but  chiefly  in  the  earlier  history  of  the  operation 
before  total  extirpation  had  been  given  up.  Liebrecht  mentions 
seven  cases  which  occurred  in  the  practice  of  Albert,  Billroth, 
and  Schoenborn.  Weiss  has  collected  thirteen  cases.*  Reverdin 
*  -'Ueber  Tetanie,"  Saiiniih  Idin.  Vortircf/e,  No.  189. 


COMPLICATIONS   AFTER   OPERATION.  317 

noticed  this  complication  in  three  cases.*  Kocher  has  had 
several  examples  in  his  practice.  Szumann  has  published  one 
case.     Schramm  and  Hicguet  f  have  also  recorded  cases. 

Most  of  the  cases  have  occurred  in  women  and  after  total 
extirpation  of  the  gland.  Reverdin's  three  cases  and  Billroth's 
ten  cases  were  all  of  this  kind.  One  of  Kocher's  patients  was  a 
boy.     Hicguet's  patient  was  also  a  boy. 

Symptoms. — Liebrecht,  speaking  of  the  seven  cases  recorded 
by  him,  says,  "  The  attacks  began  by  pain,  twitchings  and 
tingling  sensations  in  the  upper  limbs,  followed  by  intermittent 
and  clonic  spasms,  very  painful  and  of  varying  duration  and 
intensity.  The  spasms  were  sometimes  limited  to  the  upper 
limbs  and  sometimes  extended  thence  to  the  lower  limbs  and 
even  to  the  muscles  of  the  trunk,  to  those  of  respiration  and  of 
the  face.  In  the  intervals  between  the  attacks  there  was  com- 
plete intermission  of  the  symptoms." 

In  some  of  the  cases  the  symptoms  appeared  immediatelv 
after  the  operation,  in  others  not  until  several  days  had 
elapsed. 

Some  of  the  older  authors  considered  that  the  cause  of  the 
tetany  lay  in  the  circulatory  troubles,  others  that  the  symptoms 
were  of  "  reflex  spinal  origin."  There  can,  however,  now  be  no 
doubt  that  the  symptoms  are  due  to  loss  of  function  of  the 
thyroid  gland.  Similar  symptoms  have  been  produced  by 
Horsley  in  monkeys  and  other  animals  by  complete  removal  of 
this  gland. 

*  Journ.  de  la  Suisse  roin.,  1883. 

f  Bull,  de  VAcad.  de  med.  Belg.  xvii. 


CHAPTER   XXI. 

REMOTE  COMPLICATIONS— CACHEXIA  STRUMIPRIVA. 

Historical — KeverdiiT  and  Kocher — Horsley's  experiments  —  Early 
observation  of  Panl  Sick — Symptoms — Relation  to  complete  removal, 
to  partial  removal — HjiDertroiJhy  after  partial  removal — Treatment  of 
cachexia  strumipriva. 

III.  Remote  Complications. — The  remote  complications  of 
a  soitre  are  those  which  are  due  to  loss  of  function  of  the 
thyroid  gland,  and  are  comprised  under  the  terms  cachexia 
strimiipriva,  cachexia  thyreopriva,  and  operative  myxoedema. 
These  are  but  different  names  for  the  same  disease. 

In  its  most  typical  form  this  complication  is  seen  only  after 
complete  extirpation  of  the  whole  gland,  and  as  this  proceeding 
is  now  known  to  be  seldom  if  ever  necessary,  the  complication  is 
one  that  is  chiefly  of  historic  interest. 

The  credit  of  the  discovery  of  this  remarkable  affection 
belongs  to  Drs.  Reverdin  of  Geneva  and  Kocher  of  Berne. 

In  September  1882,  Reverdin  *  drew  attention  to  a  peculiar 
group  of  symptoms  which  he  had  observed  after  some  of  his 
operations  for  goitre.  Kocher  then  took  up  the  subject,  insti- 
tuted an  inquiry  among  his  own  patients  and  found  that  a 
large  number  of  them  presented  symptoms  similar  to,  or 
identical  with,  those  described  by  Reverdin.  In  April  1883, 
Reverdin  f  published  an  excellent  description  of  these  symptoms 
and  shortly  afterwards  Kocher  ii:  brought  the  matter  still  more 
prominently  forward  in  an  admirable  paper  which  he  read  at 
the  twelfth  Congress  of  Surgeons  held  at  Berlin   in  1883,  and 

*  Soc.  de  Med.,  Geneva,  Sept.  7,  1882. 

■j-  "  Note  sur  vingt-denx  operations  de  goitre,"  i^ar  J.  L.  et  A.  Eeverdin,  Rer.. 
med.  de  la  Suisse  rumande,  Geneva,  April  15,  1883. 

J  '*  Ueber  Kropfoperatiouen  imd  ihre  Folgen,"  Th.  Kocher,  Arcliir  f.  Idln. 
Chir.,  1883,  vol.  xsix.  pp.  25i-337. 


REMOTE   COMPLICATIONS.  319 

which   naturallv   attracted  great   attention.     Kocher  gave  the 


Fig.  108. — A  middle-aged  woman  Tvith  Cacliexia  Strumipriva  (opera- 
tive myxcEdema),  eleven  years  after  complete  removal  of  a  goitre.  One 
year  later  tMs  patient  died  of  cerebral  Lajmorrliage,  the  general  comlitiou 
having-  remained  nnclianged.     (Seen  at  East  Linton,  X.B.,  in  1887.) 

name  of  cachexia  strumipriva  *  to  the  disease,  while  Reverdin, 
in  a  paper  published  in  June  1883,+  suggested  that  in  some 

*  From  G-erm.  struma  =  goitre,  and  priva  =  privative, 
t  Revue  Medicale,  .June  1.5.  1883,  p.  360, 


320  THK    THYROID    GLAND. 

respects  the  sviii])tonis  olDserveci  bv  him  in  man  after  removal  of 
the  thvroid  gland  resembled  those  of  idiopathic  myxcedema, 
and  he  consequently  introduced  the  name  of  operative  myx- 
oedema  (myxoedeme  o})eratoire). 

In  this  country  Sir  Felix  Semon*  appears  to  have  been  the 
fii-st  to  make  the  definite  statement  that  "  cretinism,  myxoedema, 
and  cachexia  strumi])riva  were  merely  different  phases  of  one 
and  the  same  condition  and  due  to  one  and  the  same  cause — 
viz.,  to  arrest  of  the  function  of  the  thyroid  gland."' 

Numerous  experiments  upon  animals  performed  on  the  conti- 
nent bv  Schiff,  Zesas,  '\\'agner  and  others,  had  led  to  the  belief 
that  the  symptoms  of  cachexia  strumipriva  ^vere  produced  by 
and  were  due  to,  the  loss  of  the  thyroid  gland  itself. 

Still  further  proof  of  the  connection  between  cachexia  strumi- 
priva and  myx(£dema  was  afforded  by  the  well-known  and 
admirKble  researches  of  ^Ir.  \  ictor  Horsley.  This  observer, 
experimenting  upon  dogs  and  monkeys,  found  that  complete 
removal  of  the  thyroid  gland  produced  symptoms  identical  with 
those  seen  in  man  after  complete  removal  of  a  goitrous  thvroid. 
^Moreover,  he  found  that  in  animals  so  treated  there  was  an 
accumulation  of  mucin  in  the  subcutaneous  tissues  and  else- 
where, thus  definitely  correlating  their  condition  with  that  of 
myx(]edema  described  by  Gull  and  Ord. 

Although  Heverdin  and  Kocher  were  the  first  ^ho  gave  a  fuih 
description  of  cachexia  strumipriva,  and  connected  it  definitely 
with  removal  of  the  thyroid  gland,  yet  a  previous  observer  had 
noted  the  occurrence  of  very  remarkable  symptoms  in  a  patient 
from  whom  he  had  removed  a  goitre.  These  symptoms  are  now 
seen  to  be  the  same  as  those  of  the  disease  described  many  years 
later  bv  Reverdin  and  Kocher.  The  case  is  of  such  interest 
that  a  short  account  may  here  be  given. 

The  case  occurred  in  the  practice  of  Dr.  Paul  Sick  of  Wur- 
temberg,  and  was  published  by  him  in  the  ^^''urtemberg  Corre- 
spondenzblatt  for  1867,  vol.  3T.+ 

The  patient  was  a  boy  aged  ten,  who  had  a  goitre  as  large  as  an 
apple,   which  caused  sevei'e  dyspnoea.      On    September    11,  1866, 

*  Tniiif.  Clin,  /b'or .  1883. 

t  I  have  been  unable  to  procure  a  copy  of  the  original  paper,  but  an  excellent 
abstract  of  it  i;  given  in  Schmidt's  Jalirhui-h  for  18(i8.  vol.  cxxx\-iii.  p.  197. 


REMOTE   COMPLICATIONS. 


321 


both  lobes  of  the  gland  were  completely  removed.  The  operation 
was  a  very  severe  one^  and  was  followed  by  suppuration.  By 
November  -i  the  wound  was  completely  healed,  and  the  boy  had 
left  the  hospital.  During  convalescence  the  patient  had  had  several 
attacks  of  bleeding  from  the  nose.*  By  December  12  these 
attacks  had  ceased,  but  there  was  considerable  discharge  from  the 
nose  of  a  thin  acrid  fluid  looking  like  the  washings  of  meat  (fleisch 


Fig.  109. — A  -womau  aged  23  iu  a  late  st  ige  of  Cachexia  Strumipriva. 
A  o'oitrous  thyroid  gland  had  beeu  completelv  removel  four  years  previously, 
the  left  half  being'  extirpated  iu  .Jauiiary  1882,  the  right  half  in  the  following 
Xovember,  by  Prof.  Kocher  of  Berne.  The  photogTaph  shows  the  couditiou 
iu  August  1886.     Death  occurred  shortly  afterwards.f     (Seen  at  Berue.) 

wasserahnlich).  On  June  1,  1867,  Dr.  Sick  saw  the  patient  again. 
He  was  completely  cured ;  he  had  had  no  further  trouble  vdih 
respiration,  but  according  to  his  father's  account  he  had  become 
remarkably  taciturn  and  wrapped  up  in  himself;  but  as  regards 
capacity  and  willingness  for  work  no  change  had  been  noticed. 
The  discharge  from  the  nose  had  ceased.  Both  tonsils  showed 
considerable  enlaro-ement. 


Sick  explained  all  these  phenomena  bv  assuming  that  there 
was  increased  pressure  in  the  cerebral  circulation,  an  explanation 

*  A  point  worthy  of  note  in  connection  with  the  tendency  to  hjpmorrhage 
observed  in  myxoedema  and  some  other  thjToid  affections. 

t  This  is  one  of  the  18  cases  of  cachexia  strumipriva  originally  described  by 
Prof.  Kocher  in  his  well-known  paper. 

X 


322  THE   THYROID   GLAND. 

now  known  to  be  utterly  erroneous.  If  Ave  turn  to  another 
German  paper  we  find  the  description  of  this  same  patient's 
condition  eighteen  years  later,  when  he  was  visited  by  Prof. 
Bruns  of  Tubingen. 

This  author  writes  as  follows  :  * 

"  Being  curious  to  find  out  the  condition  of  this  patient,  I 
ascertained  that  he  still  lived,  a  cretinous  dwarf,  in  his  native 
village.  Upon  a  stout  and  boyish  body  stands  the  head  of 
a  beardless  man.  His  height  is  51  inches.  Although  the  head 
is  normal  in  size  for  a  man  of  his  age,  yet  the  body  is  that  of 
a  boy  of  ten,  in  whom  the  trunk  and  legs  are  well  proportioned. 
The  growth  of  the  body  vertically  since  the  operation  has  been 
nil.  There  is  a  markedly  idiotic  expression  on  his  face,  caused  by 
much  puffiness  of  the  whole  face,  especially  the  lips  and  lower 
eyelids.  The  skin  and  visible  mucous  membranes  are  of  a  pale 
colour.  The  skin  of  the  whole  body  is  dry  and  scaly.  The  hair  of 
the  head  is  very  thick  and  scattered.  There  is  no  beard,  but  the 
pubic  hair  and  the  genital  organs  are  fully  developed.  The  speech 
is  slow,  and  evidently  made  difficult  by  the  swelling  of  the  tongue, 
palate  and  tonsils.  On  the  neck  are  found  the  scars  of  the  opera- 
tion. The  thyi-oid  gland  is  entirely  absent.  The  trachea  and 
larynx  are  normal ;  breathing  easy ;  action  of  the  heart  weak ; 
spleen  natural ;  increase  of  white  blood  corpuscles. 

"  A  further  characteristic  feature  of  the  case  is  well  marked, 
namely,  that  while  sensibility  and  niuscitlcn'  poiver  are  preserved,  yet  the 
patient  catinot  do  work  reqiiiiing  delicacy  and  skill,  and  he  can  scarcely 
walk  Jifiy  yards.  This  incapacity  did  not  become  complete  until 
some  years  had  elapsed ;  for  when  he  left  school  at  the  age  of 
fourteen  he  was  incapable  of  learning  any  trade,  but  employed 
himself  industriously  for  many  years  in  netting,  until  he  became 
incapable  of  doing  even  this.  A  remarkable  impairment  in  his 
intelligence  has  since  occurred.  While  the  boy  before  and  just 
after  the  operation  was  one  of  the  best  pupils  in  his  school,  now 
his  mental  faculties  are  less  developed  than  those  of  a  boy  of  ten. 
His  reasoning  powei's  are  extremely  weak  and  slow.  There  is  also 
a  marked  impairment  of  sight  and  hearing." 

Since  the  date  at  which  the  above  was  written  the  patient 
has  died. 

*  "  Ueber  den  gegenwartigen  Stand  der  Kropfbehandlung,"  by  Dr.  P.  Bruns, 
Samml.  kiln.  Vortraerje,  Leipzig,  1884,  No.  244. 


REMOTE   COMPLICATIONS.  323 

The  resemblance  of  the  above  case  to  one  of  ordinary  cretin- 
ism is  obvious. 

Symptoms. — The  symptoms  of  a  well-marked  case  of 
cachexia  strumipriva  are  thus  given  by  Reverdin  :  * 

"  It  is  usually  in  the  course  of  the  second  or  third  month  after 
the  operation  that  the  patient  begins  to  complain  of  a  feeling  of 
weight  and  fatigue  in  his  limbs.  Walking  becomes  difficult.  The 
patient's  limbs  seem  to  him  heavy  and  indolent,  and  respond  but 
slowly  to  the  patient's  will.  He  is  easily  tired  and  obliged  to  rest 
frequently.  His  hands  are  often  swollen  and  clumsy.  One  patient 
is  unable  to  do  her  usual  work  of  embroidery  or  crotchet ;  another 
is  apt  to  drop  objects  which  she  is  holding.  At  the  same  time  the 
skin  becomes  pale  and  slightly  swollen.  The  pallor  is  general  and 
has  a  slightly  yellowish  white  tinge  like  that  of  anaemia.  The 
swelling,  which  may  be  general,  appears  first  of  all  in  the  face  and 
extremities,  especially  in  the  hands.  It  is  usually  very  marked  in 
the  eyelids,  and  at  once  suggests  the  idea  of  some  renal  disease ; 
nevertheless  the  urine  when  exainined  is  found  to  contain  no 
albumen ;  besides,  if  the  swelhng  be  examined  carefully,  it  is  found 
that  it  is  not  true  oedema.  The  finger  makes  no  impression  upon  it. 
The  swelling  involves  the  foi*ehead,  the  cheeks,  it  may  even  extend 
to  the  tongue.  The  features,  swollen  and  fixed,  give  to  the  patient 
an  expression  of  dulness  and  vacancy  which  recalls  that  of  a  cretin. 
The  swollen  fingers  are  hampered  in  their  movements,  and  can  no 
longer  be  flexed  completely  ;  and  to  this  mechanical  hindrance  must 
be  added  a  muscular  weakness  which  inakes  all  actions  difficult. 
Intellectual  actions  are  as  slow  as  the  movements  of  the  limbs.  If 
a  question  be  asked,  the  correct  answer  to  it  will  be  given,  but  not 
at  once.  It  will  come  slowly.  It  seems  as  if  the  patient  had  to 
make  some  effiart  to  collect  his  ideas.  Words  do  not  come  all  at 
once,  but  gradually.  Speech  is  slow.  Very  commonly  the  memory 
is  more  or  less  affected  ;  and  this  symptom  often  remains  when  the 
others  have  inore  or  less  disappeared.  .  .  .  Generally  the  skin 
becomes  dry ;  perspiration  is  suppressed ;  then  the  epidermis  becomes 
coarse  and  desquamation  is  seen  in  the  extremities,  especially  in 
the  palms  of  the  hands,  but  also  at  times  on  the  rest  of  the  body. 
The  state  of  the  skin  resembles  slightly  that  of  ichthyosis.  The 
hairs  become  dry  ;  they  break  and  fall  off  readily." 

There  is  great  chilliness  and   sensibility  to   cold.     Even  in 
summer  this  is  very  marked.     The  organs  of  sense  are  occasion- 
*  In  a  clinical  lecture  delivered.  Nov.  12,  1885,  Lyon  medicale,  1886. 


324  THE   THYROID    GLAND. 

ally  affected — taste  may  be  diminished,  vision  weakened,  hearing- 
less  acute ;  in  one  case  there  was  absolute  disappearance  of 
feeling  of  hunger  and  thirst.  Nervous  symptoms  may  be  well 
marked.  Some  patients  have  vertigo.  They  dare  not  venture 
into  the  streets.  Various  hallucinations  may  be  present. 
Epilepsv  niav  be  present  in  some  cases,  also  various  hysterical 
symptoms.  Examination  of  the  viscera  reveals  nothing  ab- 
normal. The  spleen  is  not  increased  in  size.  Examination  of 
the  blood  has  shown  that  the  red  corpuscles  are  sometimes 
decreased  in  number,  sometimes  normal.  There  is  no  increase 
in  the  number  of  the  white. 

The  symptoms  of  the  affection,  as  observed  by  Kocher,  are 
practically  identical  Avith  the  above,  which  Avill  be  seen  to  be 
those  of  mvxoedema.  A  few  other  symptoms  are  usually  also 
present  and  may  be  added  to  those  already  given.  The  abdo- 
men is  often  much  distended,  probably  from  flatulence.  Con- 
stipation is  generally  a  marked  and  troublesome  feature  of  the 
complaint.  The  temperature  of  the  body  is  almost  always 
below  normal.  The  urine  is  generally  considerably  diminished 
in  amount. 

It  is  now  well  established  that  cachexia  strumipriAa  in  its 
most  marked  form  occurs  only  after  bilateral  and  complete 
removal  of  the  whole  thyroid  gland.  If  sufficient  gland  substance 
be  left  behind  to  carry  on  the  function  of  the  organ  then  the 
symptoms  of  the  disease  either  do  not  occur  at  all  or  are  merely 
slight  and  transient.  It  is  certain  that  this  serious  complication 
always  occurs  when  the  removal  of  all  the  thyroid  tissue  has 
been  complete.  In  cases  in  which  the  whole  gland  has  apparently 
been  removed  w'ithout  the  production  of  cachexia  strumipriva, 
it  may  be  taken  for  granted  either  that  some  portion  of  the 
gland  w' as  left  behind  at  the  time  of  operation  or  that  an  accessory 
thyroid  gland  is  present. 

If  the  portion  of  gland  left  behind  be  very  small,  it  may  be 
insufficient  to  do  the  work  of  the  entire  gland.  It  will  then 
usually  undergo  compensatory  hypertrophy  and  the  supervention 
of  cachexia  strumi]5riva  is  thereby  prevented.  Sometimes  if  the 
patient  be  old  or  feeble  or  if  the  operation  be  very  severe,  death 
may  occur  from  cachexia  strumipriva  in  an  acute  form,  before 
the  remaining  gland  has  had  time   to   undergo  compensatory 


REMOTE   COMPLICATIONS.  325 

hypertrophy.  Sir  W,  Stokes  *  has  recorded,  under  the  name  of 
acute  myxoedema,  an  instance  of  this  kind. 

In  his  case,  that  of  a  woman  aged  18,  first  the  left  and  then  the 
right  half  of  a  parenchymatous  goitre  were  removed  with  an 
interval  of  three  and  a  half  months  between  the  two  operations. 
The  patient  died  twenty-one  days  after  the  second  operation  ; 
at  the  post  mortem  it  was  found  that  a  "  small  nodule  of  the 
tumour"  had  been  left  behind  on  the  front  of  the  trachea  and 
that  this  consisted  microscopically  of  "glandular  tissue  resem- 
bling that  of  the  thyroid  body." 

Figs.  19  and  20  (pp.  32,  33)  represent  the  condition  of  a  young 
woman  several  years  after  what  was  at  first  supposed  to  have  been 
a  complete  removal  of  a  parenchymatous  goitre.  The  specimen  is 
in  the  Middlesex  Hospital  Museum  f  and  shows  apparently  a  com- 
plete thyroid  gland.  The  patient  recovered  from  the  operation 
and  left  the  hospital  six  weeks  later.  She  was  at  that  time  in  a 
feeble  state  of  health.  For  the  next  two  years  she  presented 
symptoms  of  cachexia  strumipriva  shown  by  feebleness,  anaemia, 
inability  to  work,  etc.  Soon  after  leaving  the  hospital  a  small 
lump  was  noticed  at  the  upper  part  of  the  neck  on  the  left  side. 
This  slowly  increased  in  size  until  at  the  end  of  two  years,  when 
I  first  saw  the  patient,  it  had  attained  the  dimensions  of  a 
walnut.  By  this  time  the  symptoms  of  cachexia  strumipriva 
Avere  already  beginning  to  pass  off.  A  few  years  later  still  the 
tumour  had  grown  much  larger  and  the  patienfs  health  was  in 
every  way  excellent.  The  compensatory  hypertrophy  which  had 
occurred  in  the  small  portion  of  thyroid  accidentally  left  behind 
at  the  time  of  operation,  had  restored  the  function  of  the  gland 
and  all  danger  of  cachexia  strumipriva  had  disappeared. 

Fig.  110  shows  another  girl  whom  I  saw  at  the  RadclifFe 
Infirmary,  Oxford.  Six  months  before  this  photograph  was 
taken  both  lateral  lobes  of  a  parenchymatous  goitre  had  been 
removed  but  the  isthmus  had  been  left.  This  had  undergone 
compensatory  hypertrophy  and  formed  the  tumour  visible  in  the 
photograph.  No  cachexia  strumipriva  had  occurred  and  the  girlV 
health  was  excellent. 

*  Brit.  Med.  Journ.,  Oct.  16,  1886. 

t  No.  1645.  The  operation  was  performed  in  1884  by  Mr.  Henry  Morris,  ta 
whom  I  am  indebted  for  permission  to  publish  the  case. 


326 


THE   THYROID   GLAND. 


The  only  case  of  my  own  in  which  I  have  observed  any 
symptoms  of  cachexia  strumipriva  is  that  of  the  lady  shown  in 
Figs.  120  and  121,  and  in  this  case  the  symptoms  were  slight  and 
transient.     The  operation  Mas  undertaken  for  severe  dyspnoea. 


Fig.  110. — A  jouuy  woman  six  moutlis  after  removal  of  all  parts  of  a  parenchy- 
matous goitre,  except  the  isthmus,  shoTriug-  the  Re-enlargement  of 
the  latter.  There  were  no  signs  of  cachexia  strumipriva.  (Seen  at  Oxforil, 
by  the  kindness  of  3Ir.  H.  P.  Symouds.) 

The  whole  of  the  right  and  about  two-thirds  of  the  left  lobe 
were  removed.  The  operation  Mas  a  severe  one  and  the  Mound 
had  to  be  drained  OM'ing  to  the  existence  of  a  large  cavity 
behind  the  sternum  Mhich  had  been  occupied  by  the  lower  part 
of  the  left  lobe.  The  wound  healed  sloM-ly  by  granulation. 
During  convalescence  the  patient  shoM^ed  a  considerable  degree 
of  mental  and  bodily  dulness  and  apathy ;  some  of  the  hair  fell 
-out  and  the  skin  became  rouo;h  and  drv. 


REMOTE   COMPLICATIONS.  327 

After  three  or  four  months  all  these  disagreeable  symptoms 
passed  away  and  the  patient  made  a  complete  recovery. 

In  1886  I  had  the  opportunity  of  seeing  at  the  village  of 
Ltitzelfluh  in  Switzerland  a  remarkable  case  of  Professor  Kocher's, 
One  lobe  only  of  the  thyroid  was  removed  but  it  was  noticed 
towards  the  end  of  the  operation  that  the  opposite  lobe  of  the 
gland  was  atrophied  or  absent.  Typical  symptoms  of  cachexia 
strumipriva  set  in  but  the  patient  was  subsequently  cured  by 
appropriate  thyroid  ti'eatment. 

The  treatment  of  cachexia  strumipriva  like  that  of  cretinism 
and  myxoedema  is  at  the  present  day  comparatively  simple.  It 
consists  in  the  administration  in  one  form  or  another  of  thyroid 
gland  substance  {see  chap.  iii.  pp.  22,  23).  In  any  case  in  which 
large  portions  of  both  lobes  of  a  goitre  have  been  removed,  I  am 
in  the  habit  of  administering  small  doses  of  thyroid  extract  for 
several  weeks  in  order  to  prevent  the  occurrence  of  those  slight 
and  transient  symptoms  of  cachexia  strumipriva  which  might 
otherwise  occur. 


CHAPTER   XXll. 

RESULTS  OF  OPERATIONS. 

Gradual  improvement — Mortality  after  removal  of  innocent  goitre — 
Liebrecht's  and  Eeverdin's  statistics — Mortality  after  partial  extirpa- 
tion, after  ennoleatiou — Complicated  cases — ^Author's  results — Causes 
of  deatli — Relief  from  d}'spnoea — Question  of  recurrence  after  extirpa- 
tion, after  enucleation — Etteets  upon  voice — Effect  upon  general  health 
Healing  of  the  wound — Scar. 

Appexdix. — Table  of  one  hundred  consecutive  cases  of  removal  of 
g'oitre  by  extirpation  or  enucleation. 

Like  many  other  branches  of  surgery,  that  which  deals  with  the 
thyroid  gland  has  in  the  last  twenty  or  thirty  years  advanced 
very  rapidly.  Operations  such  as  removal  of  large  goitres, 
formerly  considered  to  be  dangerous  and  desperate  proceedings 
only  to  be  undertaken  in  cases  of  urgent  necessity,  may  now  be 
performed  with  comparatively  little  risk  and  in  the  vast  majority 
of  cases  with  very  great  benefit  to  the  patients.  The  frequency 
with  which  operations  upon  the  thyroid  are  now  undertaken  by 
a  very  large  number  of  surgeons  affords  evidence  of  the  progress 
which  lias  been  made  in  this  department  of  surgery. 

We  have  to  consider  now  what  is  the  average  mortality  of 
operations  upon  goitre  and  what  are  the  results  that  may  be 
expected  fi"om  these  operations. 

The  results  as  regards  exophthalmic  goitre  and  malignant 
diseases  of  the  thyroid  have  already  been  discussed  in  the 
chapters  which  deal  with  those  affections.  We  are  now  con- 
cerned only  with  the  results  of  operations  upon  innocent 
goitres. 

Various  operations  in  which  the  goitre  is  treated,  not  by 
direct  operative  removal,  but  by  other  proceedings  such  as 
tapping,  injection,  incision,  etc.,  have  been  sufficiently  discussed 
in  chap.  xv.  As  most  of  these  proceedings  are  now  well  nigh 
obsolete,  or  are,  at  any  rate  in  my   opinion,   of  but   limited 


RESULTS    OF   OPERATIONS.  329 

applicability,  nothing  more  will  be  said  of  them.  We  have 
to  consider  the  results  that  follow  removal  of  innocent  ffoitre 
by  the  two  important  operations  of  extirpation  and  enucleation 
together  with  their  various  modifications. 

Mortality. — In  discussing  the  mortality  of  operations  upon 
innocent  goitre  it  is  interesting  to  notice  the  gradual  diminution 
in  the  gross  mortality  during  successive  periods.  Liebrecht  in 
liis  exhaustive  work  published  in  1883,'*  has  collected  as  far  as 
possible  all  the  cases  recorded  up  to  that  date  and  has  given  us 
the  following  figures  for  successive  periods. 

Operations  for  Removal  of  Innocent  Goitres. 

Before  1851  : 

54  eases,  35  recoveries,  17  deaths  (31.48  per  cent.) 
Two  results  unknown. 
From  1851  to  1876: 

133  cases,  101  recoveries,  27  deaths  (20.30  per  cent.) 

Tliree  results  unknown,  two  incomplete  operations. 
From  1877  to  1882: 

l64  cases,  140  recoveries,  24  deaths  (14.63  per  cent.) 

J.  L.  Reverdin,  of  Geneva,  in  a  recent  and  very  valuable 
report  published  in  1898  has  given  us  figures  for  the  more 
modern  period  up  to  that  date.f 

The  cases  that  he  has  been  able  to  collect  amount  to  6103 
(including  a  good  many  operations  performed  before  1882)  and 
among  them  were  176  deaths,  a  mortality  of  2.88  per  cent. 
These  figures  X  show  a  very  great  improvement  upon  those  of 
the  earlier  periods. 

Too  much  faith  must  not  however  be  placed  in  statistics  of 
this  kind,  especially  when  derived  from  the  records  of  published 
cases.  Successful  cases  naturally  find  their  way  into  literature 
more  readily  than  do  the  unsuccessful  ones. 

*  "  De  rExcision  clu  Goitre  Parenchymateus,"  P.  Liebrecht,  Brussels,  1883, 
p.  248. 

t  "  Eapport  sur  le  Traitement  Chirurgicale  du  Goitre  (Cancer  et  Goitre 
Esophtalmique  Exceptes)  "  J.  L.  Eeverdiu,  Paris,  1898. 

:J;  Tliese  figures  include,  however,  a  certain  number  of  cases  of  exothyi'opexy 
and  ligature  of  thyi-oid  arteries  with  which  we  are  not  now  concerned.  They 
also  include  at  least  137  cases  of  total  extirpation,  an  operation  that  has  now 
been  abandoned  and  wMch  alone  accounts  for  26  of  the  176  deaths. 


330  THE   THYROID    GLAND. 

Reverdin's  6103  cases  were  obtained  from  three  sources. 
Published  statistics,  2120  cases  with  43  deaths ;  statistics 
communicated  privately  to  him,  but  without  details  as  to  the 
exact  nature  of  the  operation,  575  cases  with  15  deaths ;  and 
statistics  communicated  privately  with  such  details,  3408  cases 
with  118  deaths.  The  third  group  of  figures  is  the  most 
important  and  seems  worthy  of  further  consideration. 

Deducting  all  cases  of  total  extirpation,  and  all  of  exo- 
thyropexy  and  mere  ligature  of  arteries  we  are  left  with 
3254  cases  wdth  91  deaths,  a  mortality  of  2*79  per  cent. 

These  statistics  were  obtained  by  Reverdin  as  the  result  of  a 
laborious  inquiry  instituted  by  him  among  a  very  large  number 
of  surgeons  of  various  nationalities  who  were  known  to  have 
operated  upon  goitre  and  a  large  number  of  whom  replied  to 
the  inquiries  put  to  them.  It  may  perhaps  be  suggested  that 
those  who  did  not  reply  to  Reverdin's  circular  may  have  had 
worse  results  than  those  who  did.  On  the  other  hand  many  of 
the  operators  reported  operations  that  had  been  performed  as 
far  back  as  the  early  eighties  and  seventies  and  even,  as  in  one 
of  Kappeler's  cases,  from  as  early  a  year  as  1868.  The  results  of 
these  earlier  operations  were  obviously  worse  than  those  from  a 
more  recent  period. 

A  very  large  proportion  of  these  3254  operations  were  typical 
enucleations  or  typical  partial  extirpations,  and  it  is  instructive 
to  compare  the  figures  for  these  two  operations.  The  number 
of  each  is  nearly  the  same. 

There  were  1212  partial  extirpations  with  42  deaths  (mor- 
tality 3"46  per  cent.)  and  1276  enucleations  with  10  deaths 
(mortality  0.78  per  cent.)  The  extirpation  operation  is  attended, 
as  would  naturally  be  expected,  with  a  higher  mortality.  But 
it  must  not  be  forgotten  that  the  conditions  requiring  extirpa- 
tion, parenchymatous  goitre  with  severe  dyspsnoea  for  example, 
are  usually  far  more  serious  than  those  for  which  enucleation 
is  demanded. 

It  is  certain  that  if  the  surgeon  have  a  choice,  that  is 
if  enucleation  he  feasible^  it  is  usually  a  safer  and  in  this 
respect  a  better  operation. 

Enucleation  being  an  operation  of  much  more  recent  date 
than  extirpation,  it  follows  that  a  larger  percentage  of  extirpa- 


RESULTS   OF   OPERATIONS.  331 

tions  will  be  found  in  the  earlier  years  of  the  operation,  af  a 
time  when  goitre  operations  in  general  had  attained  a  lower 
degree  of  perfection  than  is  now  the  case. 

Many  of  the  operations  in  the  above  statistics  were  very 
serious  ones,  performed  upon  patients  suffering  from  severe 
dyspnaea,  upon  large  goitres  and  upon  goitres  situated  partly 
or  wholly  within  the  thorax,  and  many  of  the  operations  were 
attended  with  serious  complications,  such  as  tracheotomy 
wounds,  thyroid  fistulae  and  cardiac  and  pulmonary  complications. 
There  can  be  no  doubt  that  if  we  were  to  exclude  from  our 
statistics  all  complicated  cases  and  all  cases  in  which  the  opera- 
tion had  been  postponed  until  the  patients  were  in  extremis,  the 
average  mortality  both  of  extirpation  and  of  enucleation  would 
be  still  further  reduced. 

Reverdin^s  own  words  are  :  "  in  practised  hands,  goitre  opera- 
tions at  the  present  day  are  ahnost  free  from  danger.  If  we 
excluded  from  our  statistics  cases  of  long;  standing;  on  the  one 
hand  and  complicated  cases  on  the  other,  it  is  probable  that  the 
general  mortality  would  be  but  little  above  0." 

Turning  now  to  the  statistics  of  my  own  operations  the  total 
number  of  operations  performed  for  the  removal  of  goitre  of  all 
kinds  up  to  the  present  time  (end  of  December  1900)  is  a 
hundred  and  twenty-six. 

They  include  operations  upon  patients  of  all  ages  from  ten  to 
sixty- nine,  undertaken  for  the  most  part  on  account  of  dyspnoea, 
often  very  severe.  The  tumours  removed  were  of  various  sizes 
and  up  to  more  than  three  pounds  in  weight  {see  Fig.  34). 
A  large  number  of  them  extended  partly  or  even  largely  into 
the  thorax.  In  eleven  out  of  the  hundred  and  twenty-six  cases 
the  operation  was  performed  upon  both  sides  of  the  gland  at 
once.*'  The  mortality  in  the  earlier  cases  was  considerably 
greater  than  in  the  later  ones. 

Among  the  first  twenty-six  cases  there  were  four  deaths  (all 
extirpation  cases).  All  these  cases  have  been  mentioned  in 
chap.  XX.  In  two  of  them  the  operations  were  formidable 
ones  and  were  performed  upon  large  goitres  ;  one  of  the  patients 

*  Cases  in  which  extirpation  was  performed  on  one  side  and  enucleation  on 
the  other  are  included  among  extirpations  only. 


332  THE   THYROID   GLAND. 

had  also  valvular  disease  of  the  heart.    Among  the  last  hundred 


Fig.  111. — Laroe  bilateral,  maiulj-  adenomatous,  goitre,  in  a  man  aged  27 
The  left  lobe  (see  Fig-.  114)  was  extirpated  on  acconnt  of  dyspnoea. 


Fig.  112. — The  same  patient  twelve  daj's  after  the  operation.* 

cases,  details  of  which  are  given  on  pp.  343-345,  there  was  but 
one  death.    This  was  in  the  case  of  a  boy  aged  eighteen  (case  46), 

*JA^full  account  of  this  case  has  been  published  by  Dr.  Edward  Jessop  and 
myself  in  the  aS'^.  Bart.  Hosp.  Beps.  1889.  xxv.  p.  97. 


RESULTS   OF   OPERATIONS. 


333 


who  had  a  large  bilateral  parenchymatous  goitre.     Death  was 
due  to  recurrent  arterial  haemoiThage  caused  by  faulty  ligation 


Fig.  113. — Sectiou  of  the  goitre  showu  iu  Fig.  111.  In  the  upper  third  of  the 
.specimen  are  two  large  adeuomata  almost  wholly  solid.  In  the  middle  third 
are  two  adenomata  which  liave  broken  down  and  formed  cysts.  One  of  these 
is  nearly  filled  with  a  mass  of  coagulated  colloid.  In  the  lower  third  are 
otlier  adenomata  with  a  good  deal  of  fibrous  tissue.  (St.  Bart.  Hosp.  Mus. 
Xo.  2310c.)     (Fteduced  |.) 


of  an  abnormally  situated  thyroid  artery.  The  last  eighty  cases 
have  been  attended  by  no  death  or  serious  complication  of  any 
kind. 

The  high  mortality  among  the  earlier  cases  is  to  be  attributed 


334 


THE   THYROID   GLAND. 


undoubtedly  to  personal  inexperience  and  want  of  dexterity  in 
operating.  It  is  not  due  to  any  essential  difference  in  the 
nature  of  the  cases  operated  upon.  Indeed  the  largest  operations 
and  those  attended  by  most  dyspnoea  have  been  among  those  of 
the  later  series. 

Causes  of  Death. — Reverdin  in  his  report  gives  an  instructive 
table  showing  the  causes  to  which  the  deaths  were  attributed. 
The  following  is  that  part  of  it  which  relates  to  partial  extirpa- 
tion and  to  enucleation. 


p 

SufFocation 

artial 

Extii'pation. 
1 

Enucleation 
4 

Pneumonia,     broncho-pneumonia, 
and  bronchitis 

18 

3 

Syncope .... 
Lesions  of  recurrent  nerve 

2 
1 

— 

Collapse  .... 
Tetany    ..... 
Myxcedema  and  tetany    . 
Haemorrhage  . 

1 
1 

1 
6 

— 

Septicaemia 
Mediastinitis    . 

7 
1 

— 

Various  and  unknown 

3 

3 

42 


10 


It  will  be  seen  tiiat  pulmonary  complications  and  septicaemia 
account  for  more  than  half  the  total  number  of  deaths,  Avhile 
next  to  these  in  importance  comes  haemorrhage.  Doubtless  many 
of  the  eighteen  cases  under  the  heading  of  pulmonary  complica- 
tions might  fairly  be  classed  among  septic  complications. 

If  the  earlier  cases  could  be  separated  from  the  later  ones 
we  should  find  that  the  complications  more  or  less  under  the 
control  of  the  surgeon,  namely  septic  complications  and  haemor- 
rhage, were  less  frequent  in  the  later  cases. 

With  regard  to  this  point,  Reverdin  quotes  the  statistics  of 
Kronlein,  who  in  his  first  series  of  cases  had  four  deaths,  of 
which  two  were  due  to  suppurative  mediastinitis,  one  to 
pneumonia  and  one  to  collapse;  in  his  second  series  he  had 
three  deaths,  none  of  which  were  due  to  sepsis ;  one  was  due  to 
cardiac  trouble  and  two  occurred  in  patients  who  were  the 
subjects  of  suffocating  goitres. 


RESULTS   OF   OPERATIONS. 


335 


a  .^' 

o  .5 
©    5 

<^ 

•r-l 

'o 

02 


336  THE   THYROID    GLAND. 

The  five  deaths  in  my  own  practice  ^vere  due,  as  already 
mentioned,  to  chloroform,  shock  and  httmoiThage,  while  none 
were  attributable  to  any  form  of  sepsis  or  pulmonary  trouble. 

Turning  now  to  the  results  of  the  operations  in  cases  that 
recovered,  and  referring  only  to  my  own  operations,  we  have  to 
consider  various  points. 

Relief  from  Dyspncsa. — In  all  my  cases,  hitherto,  the  relief 
from  dvspn(jea  has  been  complete  and  permanent,  so  that  a 
second  operation  has  never  vet  been  necessary.  In  a  very  small 
percentage  of  cases  operated  upon  bv  others,  second  operations 
have  been  necessary.  These  have  generally  been  in  cases  in 
which  the  first  operation  has  been  upon  one  lobe  onlv,  and  in 
which  disease  of  the  opposite  lobe  has  subsequently  demanded 
operative  interference. 

Recurrence  of  the  G-oitre. — This  naturally  depends  largely 
upon  the  nature  of  the  goitre  and  of  the  operation  performed. 

Unilateral  extirpation  of  one  lobe  of  a  parenchymatous  goitre 
is  almost  invariably  followed,  at  first,  by  diminution  in  the  size 
of  the  opposite  lobe.  This  diminution  in  size  is  usually  followed 
after  some  months,  by  re-enlargement  of  the  remaining  lobe  up 
to  a  certain  point.  If  the  cause  which  originally  produced  the 
goitre  continues  to  act,  the  remainder  of  the  goitre  may  con- 
tinue steadily  to  increase  in  size,  but  rarely  to  such  a  point  as 
to  render  further  operation  necessary.  To  a  certain  extent,  the 
re-enlargement  of  the  remaining  lobe  may  be  regarded  as  com- 
pensatory hypertrophy.     {See  remarks  on  p.  31.) 

The  question  of  recurrence  after  enucleation  depends  mainly 
upon  the  state  in  which  the  remainder  of  the  gland  is  left.  The 
adenoma  or  cyst  that  has  been  removed  cannot  of  course  return.* 
But  an  adenoma  is  frequently  surrounded  by  other  smaller 
adenomata  or  cvsts,  and  these  may  continue  to  grow  after  the 
enucleation  has  been  performed,  or  an  adenoma  may  be  imbedded 
in  a  parenchymatous  goitre,  and  after  the  removal  of  the 
adenoma,  further  growth  of  the  parenchymatous  portion  may 
take  place. 

It  is  in  young  people  more  especially  that  such  recurrence  of 
the  goitre  is  apt  to  occur.      One   of  the  objections  that  may  be 

*  "Malignant  adenomata"  and  papuliferous  cysts  are  of  course  not  now  under 
consideration. 


RESULTS    OF   OPERATIONS. 


337 


raised  to  the  operation  of  enucleation  is  that  sometimes  it  does 
not  remove  enough  of  the  goitre. 

In  a  case  of  multiple  adenomata  it  is  often  difficult  to  decide 
whether  it  is  better  to  perform  enucleation  of  one,  two,  or  more, 
of  the  tumours  *  knowing  that  others  will  be  left  behind,  or 
whether  an  extirpation  of  the  whole  lobe,  tumours  and  all,  is 
not  a  preferable,  although  probably  a  more  serious,  operation. 


Fig.  116.— a  patient  aged  31,  showing-  a  Transverse  Soar,  eleven  months 
after  enucleation  of  a  cystic  adenoma  as  large  as  a  hen's  egg.  (.See 
Appendix,  Case  94,  p.  350.) 

As  a  general  rule,  if  there  is  a  small  number  of  relatively  large 
adenomata,  it  is  best  to  perform  enucleation.  If,  on  the  other 
hand,  numerous  adenomata  exist  which  are  of  nearly  the  same 
size,  then  extirpation  of  one  lobe,  combined  if  necessary,  with 
enucleation  of  one  or  more  tumours  from  the  other  lobe,  is 
generally  the  best  operation. 

Effect  upon  the  Voice.— Damage  to  the  recurrent  nerve 
may  produce  paralysis,  partial  or  complete,  of  a  vocal  cord.  It 
is  exceedingly  rare  after  enucleation,  but  it  is  not  very  uncommon 

*  See  Case  88,  p.  350,  in  which  I  enucleated  no  less  than  five  adenomata 
at  one  sitting. 


338 


THE   THYROID    GLAND. 


after  extirpation,  in  which  the  nerve  is  more  liable  to  injury.  I 
have  already  mentioned  that  in  one  only  of  my  126  cases,  so 
far  as  I  am  aware,  did  paralysis  of  a  vocal  cord  supervene  soon 
after  the  operation.  This  was  a  case  in  which  some  suppuration 
took  place  after  a  bilateral  operation  (case  41)  in  which  ex- 
tirpation was  performed  on  one  side   and   enucleation  on  the 


Fig.  117.— Showing  u  Bad  Oblique  Scar  iu  a  womau  aijcJ  32,  six  moutlib; 
after  cuiicleation  of  au  adeuoma  of  tlie  left  lobe,  Tlie  scar  is  ^\ide  autl 
somewhat  thick.     (See  Appendix,  Case  67,  p.  348.) 


other.  In  three  other  cases,  however,  paralysis  of  a  yocal  cord 
was  found  to  have  gradually  occurred  as  the  result  of  compres- 
sion of  the  nerve  by  the  scar.  Compensation  was,  however,  so 
perfect  that  no  alteration  in  the  voice  was  noticeable.  Two  of 
these  were  cases  of  extirpation,  and  were  among  my  earlier  opera- 
tions. It  is  possible  that  some  similar  instance  of  paralysis  of  a 
cord  may  have  occurred  unknown  to  me,  since  I  have  not  been 


RESULTS   OF   OPERATIONS.  339 

able  to  examine  all  my  patients  long  after  the  operation.  But 
this  has  been  done  in  the  great  majority  of  mv  cases,  and  up  to 
the  present  time  the  above-mentioned  cases  are  the  only  instances 
of  paralysis  of  a  cord  that  have  been  detected. 

Effect    on    the    General    Health. — Total    removal    of    the 


Fig.  118. — A  woman  aged  51,  six  years  after  removal  of  a  bilateral  goitre 

(extirpation  on  tlie  right  side,  enucleation  on  the  left).  The  Scar,  altliougli 

vertical,  is  fine,  linear,  and  scarcely  visible.     (Case  17.     See  Eoyal  Free 
Hosp.  Mns.  Xo.  xxii.  22.)  * 

thyroid  gland  having  never  been  performed  by  myself,  I  have  no 
case  of  pronounced  cachexia  strumipriva  (myxoedema)  to  record. 
One  case  in  which  slight  and  transient  symptoms  of  this  affec- 
tion lasted  for  a  few  months  after  a  severe  operation  upon  both 
lobes  of  the  gland  has  been  recorded  on  p.  326  (case  41). 

In  a  few  cases  in  which  extensive   operations  were  performed 

*  Published  iu  Brit.  Med.  Jimrn.,  July  7,  1900. 


340 


THE   THYROID   GLAND. 


t> 

CO 

\^ 

a 

o 

„ 

rt 

-^ 

o 

" 

' 

ci 

O 

o 

_J^" 

_^ 

^ 

H 

■^ 

s 

cS 

8 

^ 

cS 

Sc^ 

8 

r-i 

a 

2 

\^ 

a 

A 
o 

I—* 

i 

g 

ci 

r^ 

o 

« 

=! 

a 

^ 

r^ 

.^ 

a 

^ 

C5 

^  a 


S  -3 


RESULTS   OF   OPERATIONS. 


341 


upon  one  or  both  lobes  of  the  goitre,  pallor  and  general  weak- 
ness have  been  noticed,  which  have  seemed  to  be  greater  than 
those  which  usually  follow  operations  of  similar  magnitude  upon 
most  other  parts  of  the  body.  These  svmptoms,  which  were 
probably  due  to  temporary  interference  with  the  functions  of 


Fig.  121. — The  precediut;-  (Fig.  119;,  several  mouths  alter  extirpation  of  tlie 
whole  ol  the  riglit  lobe  and  most  of  the  left  lobe.  The  iuli-a-hyoid  muscles 
were  not  sutured,  and  the  Sear  is  consequently  deeply  depressed 
and  ugly.     (See  Appendix,  Case  41,  p.  344.) 


the  gland,  have  invariably  been  transient  and  have  given  rise  to 
no  anxiety  or  alarm.  They  have  rarely  lasted  more  than  two  or 
three  months.  They  have  usually  been  treated  by  iron,  strychnia, 
and  other  general  tonics. 

In  the  great  majoritv  of  cases,  the  general  health  of  the 
patient  has  been  improved  by  the  operation.  Palpitation, 
lassitude,    and    other    symptoms    that    have    frequently   been 


.'i42  THE    THYROID    GLAND. 

prominent  before  the  operation,  have  in  most  instances  either 
greatly  diminished,  or  completely  disappeared,  after  the  removal 
of  the  goitre.  These  beneficial  effects  following  the  removal  of 
a  local  disease  are  to  be  explained,  I  believe,  chiefly  by  the 
removal  of  local  pressure.  The  freedom  from  dvspnoea  enables 
the  patient  to  take  far  more  exercise  than  before,  and  thus 
improves  the  general  health. 

Healing  of  the  Wound. — In  104  of  my  126  cases,  the  wounds 
healed  by  primary  union  throughout.  In  ten  cases  the  wounds 
healed  almost  by  primary  union,  but  a  small  sinus,  generally  in 
the  track  of  a  drain,  remained  open  for  a  few  days.  In  seven 
cases  a  sinus  resulted  which  remained  open  for  periods  varying 
from  several  weeks  to  several  months  (in  one  case  nearly  a  year). 
In  all  these  latter  cases  the  supj^uration  was  of  a  very  mild  type 
and,  except  for  a  short  time  after  the  operations,  the  patients 
were  able  to  go  about  and  pursue  their  ordinary  avocations 
during  the  slow  healing  of  the  sinus.  Of  profuse  and  really 
dangerous  suppuration  I  have  no  case  to  record.  A  permanent 
fistula,  such  as  is  seen  sometimes  after  injection  and  of  which 
Fig.  86  is  an  example,  is  a  condition  that  has  never  occurred 
after  any  of  my  operations. 

The  Sear. — As  has  already  been  mentioned  in  chap.  xvii. 
the  nature  of  the  scar  depends  to  a  considerable  extent  upon 
the  direction  in  which  the  skin  incision  has  been  made.  Trans- 
verse wounds  healing  by  primary  union  almost  in\'ariably  leave 
fine  linear  scars  often  scarcely  noticeable  when  the  redness  has 
passed  off.  Such  scars  are  shown  in  Figs.  96  and  116.  Vertical 
and  oblique  scars  in  young  people,  even  when  the  ^vounds  have 
healed  bv  primary  union,  have  a  considerably  tendency  to  widen 
and  become  unsightly.  (.SV^  Fig.  117.)  They  sometimes 
become  thick,  prominent  and  ugly,  assuming  a  keloid  nature. 
In  elderly  people,  on  the  other  hand,  this  tendency  is  very 
slightly  marked.  {See  Figs.  105  and  118.)  Wounds  that  heal 
by  granulation  naturally  leave  worse  scars  than  those  that  heal 
by  primary  union. 


APPENDIX. 

ONE  HUNDRED  CONSECUTIVE*  CASES 

OF 

REMOVAL   OF   GOITRE   BY   OPERATION 

(EXTIEPATIOX  AND  EXUCLEATIOX) 
PERFORMED  BY  THE  AUTHOR  8IXCE  FEBRUARY  1894. 


SUMMARY  OF  THE  FOLLOWING  TABLE. 


CASES. 

EKIES. 

DEATHS. 

Extirpations 

Bilateral    . 

5 

5 

0 

Unilateral           .... 

21 

20 

1 

Extirpation  on  one  side  combined  with 

enucleation  on  the  other 

1 

] 

0 

Enucleations 

Bilateral 

3 

3 

0 

Unilateral           .... 

70 

70 

0 

100       99 


*  One  other  case,  of  a  large,  fixed  and  hopelessly  irremovable,  malignant 
goitre,  in  which  a  portion  of  the  tumonr  was  removed  merely  to  allow  of  access 
to  the  trachea  for  the  purposes  of  an  immediate  and  urgent  tracheotomy,  has 
not  been  included  in  the  list. 


(      34.4.      ) 

ONE  HUNDRED  CONSECUTIVE  CASES  OF  REMOVAL  OF 

Performed  by  the  Author  between 


No. 

Date  of 
Opera- 
tion. 

Name. 

Chief  Reason  for 
Operation. 

Operation. 

Nature  of  Goitre. 

1 

1894 

27* 

March  17 

Barkland 
C.  (male) 

15 

Dyspnoea, 
dysphagia 

Extirpation, 
■whole  of  right, 
one  third  of  left 

ParenchjTiiatous  ;  8  oz. 

R. 

28 

March  27 

James  H. 

21 

Dyspnoea 

Extirpation, 

right  lobe  and 

isthmus 

Parenchpnatous  ;  6  oz. 

R. 

29 

July  1 

Mr.  R.  B. 

30 

Deformity 

Enucleation 

Prominent  cyst  size  of  golf  ball 
in  front  of  larynx 

R. 

30 

July  20 

Mary  H. 

39 

Severe  dyspnoea 

Extirpation, 

right 

Parenchymatous  «ith  cystic 

adenomata ;  4i  x  3  in. :  8  oz. : 

partly  sulisternal 

R. 

31 

Oct.  13 

Constance 
K. 

10 

Dyspnoea 

Extirpation, 

right  and  part 

of  left 

Parenchymatous;  4-}x2iin. ; 
weight  of  right  4  oz' 

R. 

32 

Nov.  3 

Kate  M. 

20 

Dyspnoea, 
dysphagia 

" 

Parenchymatous ;  4i  x  3i  in. ; 
Vih  oz. ;  partly  substernal 

R. 

33 

Dec.  5 

1895 

Ellen  S. 

15 

Dyspnoea 

" 

ParenehjTuatous ;  extending 
into  thorax 

R. 

34 

March  7 

Ellen  N. 

43 

Severe  dyspncea 

Extirpation, 
right  and  isthmus 

Parenchymatous ;  4  x  5  in. ; 
7  oz. 

R. 

35 

March  31 

3Iiss  S. 

25 

Deformity 

Enucleation 

Cystic  adenoma  (one-third 
solid) ;  2i  in.  in  diaineter 

R. 

36 

May  18 

Margaret 

15 

Dyspnoea 

Extirpation,  left 

Parenchyruatous ;  very  large 
goitre  (Figs.  22,  23) 

R. 

37 

Sept.  20 

IMi-s.  B. 

41 

Dyspnoea 

Extirpation,  left 
and  part  of  right 

Parenchymatous;  i{  oz. 

R. 

38 

Dec.  16 
1896 

Hannah  D. 

50 

Malignancy 

Extirpation,  left 
and  isthmus,  and 
small  part  of  right 

2  X  IJx  1  in. ;  pale  non-encap- 

suled  timiour,  surrounded  hy 

thick  layer  of  healthy  thyroid 

gland ;  microscopically 

malignant 

R. 

39 

feb.  1 

Mrs.  W. 

38 

Deformity ; 
slight  dyspnoea 

Enucleation,  left 

Cystic  adenoma  size  of  walnut 

R. 

40 

Feb.  29 

Clara  S. 

16 

Dyspnoea, 
dysphagia 

Enucleation, 
right 

Cystic  adenoma ;  li  in.  in  dia- 
meter ;  partly  substernal 

R. 

41 

March  8 

:Miss  H. 

43 

Dyspnoea 

Extirpation, 

right  and  most 

of  left 

ParenchjTuatous ;  llf  oz. ; 
partly  substernal  (Figs.  119, 120) 

R. 

42 

May  28 

Sarah  P. 

25 

Deformity,  dis- 
■    placement  of 
trachea 

Enucleation, 
right 

Cystic  adenoma,  one-third 
solid  ;  size  of  hen's  egg 

R. 

43 

Oct.  3 
1897 

Kate  C. 

26 

Dyspnoea 

" 

Cystic  adenoma,  two-thirds 
solid ;  2i  oz. 

R. 

44 

March  27 

Lilla  W. 

14 

Slight  dyspnoea 

» 

Cystic  adenoma  size  of  orange 

R. 

45 

May  17 

Mrs.  J. 

37 

Severe  dyspnoea 

" 

Solid  adenoma  ;  3x2}  in.  ; 
largely  substernal 

R. 

46 

May  22 

Francis  L. 

18 

Slight  dyspnoea ; 
tracheal  stenosis 

Extirpation, 
right 

Parenchj-matous ;  lOA  oz. 

D. 

Cases  1  to  26  have  already  been  published  in  the  Brithh  Medical  Journal,  June  1891  and  July  1900. 


(     345     ) 

GOITRE  BY  OPERATION  (EXTIRPATION  AND  ENUCLEATION). 
Fehniaiy  1894  and  Januaiy   1901. 


Drainage ;  primary  union 


Drainage ;  primary  union  except 

in  track  of  tube 

Drainage ;  primary  union 


No  drainage ;  primary  union 

Drainage ;  primary  union  except 
in  track  of  tube ;  sinus  healed  in 
fortniglit ;  considerable  collapse ; 
temporary  paresis  of  sympathetic 

Drainage ;  primary  union 


No  drainage ;  primary  union 


Drainage ;  primary  union 


Drain  age ;  mild  suppuration ; 
sinus  for  8  months ;  operation 
prolonged  and  very  severe ;  in- 
frahyoid muscles  not  sutured ; 
slight  syrnptoms  of  cachexia 
strumipriva  for  some  weeks 
Drainage ;  primary  union 


Drainage ;  operation  long  (nearly 
2  hours),  but  presented  no  unusual 

difficulty ;  profuse  recurrent 
haemorrhage  4  hours  after  opera- 
tion ;  wound  opened  up  by  house- 
surgeon  ;  death  15  hours  latei' 


SO 


C  ftOJ 


100.2° 

100.2° 

(?) 

99.8° 

100.4° 

100.0° 
104.0° 
100.2° 
100.0° 
101.4° 


98.8° 


(?) 
99.2° 


100.2° 
99.4° 
101.4° 
101.8° 


a  X 


(?) 


(?) 


Oblique 


Median 


Oblique 


Median 

Trans- 
verse 
Oblique 
<Fig.  121) 


Trans- 
verse 


Oblique 

Trans- 
verse 
Oblique 


Chloro- 
form 


Latest  Report  (and  Source  of). 


Chloro- 
form 


July  1899.— Quite  well  (letter) 


Jan.  1895.— Quite  well  (personal 
observation) 

July  1898.— Quite  well  (personal 
observation).  July,  1899. — Quite 
well  (Dr.  Eminson,  Scotter,  Lin- 
colnshire) 
July  1899. — Quite  well  (personal 
observation) 

July  1899.— Quite  well  (Dr. 
Powell,  Melton  Mowbray) 

July  1899.— Quite  well  (Dr.  Gil- 

bertson,  Hitchin) 
July  1899.— Quite  well  (personal 

observation) 

July  1899.— Quite  well  (personal 

observation) 

July  1899.— Quite  well  (letter) 

Nov.  1895. — Rather  aniemic,  other- 
wise quite  well ;  no  local  trouble 
(personal  observation).  -July,  1899. 
In  service  and  believed  to  be  quite 

well  (Dr.  Maund,  Newmarket) 
Jan.  1901.— Quite  well ;  consider- 
able enlargement  of  right  lobe, 
causing  no  trouble  (personal 
observation) 
July  1899.— Quite  well ;  no  recur- 
rence (personal  observation) 


July  1899.— Quite  well  (Dr.  Fer- 
gusson,  Painswick,  Gloucester) 
July  1899.— Quite  well  (Dr.  Fer- 
gnsson,  Painswick,  Gloucester) 
June  1899.— General  condition 
excellent ;  not  the  slightest  dysp- 
noea or  trouble  of  any  kind  except 
some  weakness  of  voice  at  times ; 
left  vocal  cord  paralysed  (personal 
observation) 
Quite  well  on  leaving  hospital ; 
not  heard  of  since  (address 
changed) 
July  1899.— Quite  well  (letter) 

July:i899.— Quite  well  (Dr. 

Skelding,  Bedford) 

May  1898.— Quite  well  (letter) 


t  Temperature  taken  every  four  hours. 


(     3-i6     ) 

ONE  HUNDRED  CONSECUTIVE  CASES  OF  REMOVAL  OF 

Performed  by  the  Author  hettveen 


Ko. 

Date  of 
Opera- 
tion. 

Name. 

6 
< 

Chief  Reason  for 
Operation. 

Operation. 

Xature  of  Goitre. 

1 

47 

July  17 

Albert  R. 

22 

Dyspnoea 

E.xtirpation, 
right 

Parenchymatous ;  7i  ( )z. 

R. 

4S 

.Tuly  22 

Sarah  Ann 
H. 

40 

" 

Parenchjnnatous  with  adeno- 
matous nodules ;  partly 
su))sternal ;  11  oz. 

R. 

49 

Sept.  16 

Eliza  B. 

46 

Dyspnoea,  dys- 
phagia; recent 

increase  in  size ; 

suspected  malig- 
nancy 

Extirpation, 
right,  enuclea- 
tion, part  of  left 

Solid  adenomata ;  3*  oz. ;  right 
size  of  orange,  left'of  walnut 

R. 

50 

Sept.  30 

Lucy  S. 

38 

Dyspnoea 

Extirpation, 
right 

Solid  adenoma ;  7^f  oz. 

E. 

51 

Oct.  16 
1S98 

Edith  W. 

IS 

Dyspnoea, 
dysphagia 

Enucleation,  left 

Two  tmiiours.— 1.  Hemorrha- 
gic cystic  adenoma,  size  of  wal- 
nut.   2.  Solid  adenoma,  size  of 
hazel  nut 

R. 

52 

Jan.  23 

Mrs.  F. 

39 

Dyspncea 

Enucleation, 
right 

Solid  adeuc)ma,  size  C)f  large 

walnut ;  deeply-seated  and 

projecting  from  back  of  gland 

R. 

53 

Jan.  29 

Louisa  H. 

54 

Severe  dyspncea 

" 

Solid  adenoma,  size  of  large 

lemon ;  partly  substernal ;  6  oz. 

(Figs.  91,  92) 

R. 

54 

-March  2 

Miss  P. 

25 

Dyspncea 

Enucleation,  left 

Cystic  adenoma,  one-third 
solid,  size  of  duck's  egg 

K. 

55 

May  7 

Eenee  C. 

'-' 

Dyspncea 

Enucleation, 
right 

Solid  adenoma,  size  of  an 

orange ;  the  tumour  was  broken 

up  and  removed  through  an 

incision  2i  in.  long 

R. 

56 

ilay  13 

Charlotte 
0. 

40 

Rapid  gro^rtli ; 
hardness;  sus- 
pected malig- 
nancy 

Extirpation, 
right 

A  hard,  white,  shiny  solid 

tumoiu-,  size  of  a  hen's  egg, 

microscopically  not  malignant 

R. 

May  13 

Alice  B. 

30 

Dyspnoea, 
dysphagia 

Enucleation, 
left  (atjpical) 

Solid  tumour,  not  well  encap- 
suled ;  about  li  in.  in  diameter 

R. 

5S 

May  21 

Emily  M. 

33 

Dyspncea 

Enucleation, 
right 

Solid  adenoma,  size  of  orange ; 

broken  uj)  and  removed  through 

incision,  ih  in.  long  (Fig.  99) 

K. 

59 

May  21 

Harriet  S. 

25 

Dyspnoea 

Enucleation, 
right  and  left 

R.  hsemorrhagic  cyst,  size  of 

hen's  egg.    L.  cystic  adenoma, 

size  of  orange 

R. 

60 

July  9 

Charlotte 
J. 

54 

Dyspncea 

Enucleation, 
right 

Cystic  adenoma  with  hemor- 
rhage ;  three-fourths  solid  ; 
3x2  in. ;  patient  also  had 
cancer  of  breast 

R. 

61 

Oct.  6 

Eliza  J. 

50 

Dyspncea,  great 
deformity 

Enucleation 

Cyst  5  in.  in  diameter  (Fig.  65) 

E 

62 

Oct.  6 

Harriet  M. 

48 

Tracheal  dis- 
placement ;  in- 
creasing size ; 
slight  dyspnoea 

Enucleation,  left 

Cystic  adenoma,  chiefly  fluid  ; 

maximmu  diameter  5  in. ; 

13  oz.  (Fig.  103) 

R. 

63 

jS'ov.  26 

Khoda  S. 

59 

Dyspncea 

Enucleation,  left 

Cystic  adenoma,  mainly  fluid ; 

4  X  2i  in. ;  patient  has  valvular 

disease  of  heart 

R. 

(      347     ) 

GOITRE  BY  OPERATION  (EXTIRPATION  AND  ENUCLEATION). 

February   1894  and  January   1901. 


^  o 

g  ^  o    . 

a--;  0)  o 

o-?.a  '-^ 

H  t 

7^   S    "r- 

_o 

2 

Remarks. 

SO 

Days  aftei 
tion  on 

Temp,  rea 
exceede( 

^ 

1 

-5 

Latest  Report  (and  Source  of). 

Drainage ;  primary  union 

101.0° 

3 

Oblique 

Chloro- 
form 

July  1899.— Quite  well  (Dr.  Haig 
Brodie,  Battle) 

101.4° 

5 

Mor- 
phine 
and  co- 
caine 
only 

July  1899.— Quite  well  (Dr.  Per- 
ram,  Whitchurch,  Salop) 

"               "           " 

101.8° 

2 

" 

Chloro- 
form 

July  1899.— Quite  well  (personal 
observation) 

,,               ,,           ,, 

100.6° 

2 

,, 

„ 

Ditto 

" 

100.2° 

1 

Trans- 
verse 

" 

Ditto 

,- 

99.8° 

Oblique 

" 

April  1899.- Quite  well  (personal 
observation) 

„ 

100.4° 

Trans- 
verse 
(Fig.  93) 

" 

July  1899.— Quite  well  (personal 
observation) 

"               " 

100.8° 

1 

Trans- 
verse 
(Fig.  9C) 

" 

June  1899.— Quite  well  (personal 
observation) 

"               "           " 

101.0° 

1 

Trans- 
verse 

" 

Quite  well  on  leaving  hospital ; 

not  heard  of  since  (address 

changed) 

" 

99.8° 

Oblique 

" 

July  1899. — Quite  well  (personal 
observation) 

102° 

Nov.  2, 1898.- Quite  well  (personal 

(tejiip. 

observation).    July  1899.— Well 

100°  be- 

as  regards  neck,  but  ill  with  renal 

fore'ope- 

disease  (letter) 

ration) 

" 

100° 

1 

Trans- 
verse 
(Fig.  100) 

" 

July  1899.— Quite  well  (Dr. 
Pruen,  Cheltenham) 

" 

100.8° 

1 

Oblique 

" 

July  1899.— Quite  well  (Dr.  Ken- 
dall, Chiddingfold,  Surrey) 

,. 

99.  C° 

" 

" 

July  1899.— Quite  well  (Dr.  R.  M. 
West,  Leicester) 

100.4° 

1 

Oblique 

Mor- 

July 1899  —Quite  well  (Dr.  Rich- 

(Fig. 06) 

phine 
and  co- 
caine 
only 

ardson,  Alverstoke) 

100.4° 

1 

Oblique 

July  1899.— Quite  well  (personal 

(Figs. 

observation) 

104,  105) 

„ 

100.0° 

1 

Oblique 

" 

June  1899.— Quite  well  (personal 
observation) 

t  Temperature  taken  every  four  hours. 


(     348     ) 

ONE  HUNDRED  CONSECUTIVE  CASES  OF  REMOVAL  OF 

Performed  hy  the  Author  between 


Nos 

Date  of 
Opera- 
tion. 

Name. 

6 

Chief  Reason  for 
Operation. 

Operation. 

Nature  of  Goitre. 

3 
1 

W 

Nov.  26 

Edith  C. 

27 

Dyspnica ; 
dysphagia 

Enucleation, 
right 

Hemorrhagic  cystic  adenoma ; 
partly  substernal ;  three-quar- 
ters solid  ;  2  in.  in  diameter 

R. 

65 

Nov.  28 
1899 

:Mrs.  W. 

30 

Extreme  bi- 
lateral tracheal 
stenosis;  old 
tracheotomy 
fistula 

Enucleation, 

right  (March  14, 

1899,  plastic 

operation  on 

tracheal  fistula) 

Solid  adenoma,  size  of  large 
walnut 

R. 

66 

Jan.  7 

Annie  L. 

24 

Tracheal 
narrowing 

Enucleation, 
right 

Cystic  adenoma,  two-thirds 

solid,  size  of  walnut;  deeply 

seated 

R. 

67 

Jan.  7 

AdaH. 

32 

Steady  increase 
in  size ;  dyspnoea 

Enucleation,  left 

Cystic  adenoma,  two-thirds 
solid,  size  of  hen's  egg 

R. 

68 

.Jan.  13 

Miss  S. 

35 

Deformity,  dis- 
placement of 
trachea 

Enucleation 

Solid  adenoma,  size  of  hen's 
egg 

R. 

69 

Jan.  14 

Caroline  T. 

43 

Dyspnoea 

Enucleation, 
right 

Solid  adenoma,  2i  x  li  in. 

R. 

70 

Jan.  28 

Phoebe  H. 

14 

Dyspnoea 

Extirpation, 
right 

Parenchymatovis ;  3x2  in. ; 
3  oz. 

R. 

71 

Jan.  28 

Ernest  W. 

14 

Slight  dyspnoea ; 
defoiniity 

" 

Parencliymatous ;  3ix2in. 
3oz. 

R. 

72 

Feb.  17 

Miss  N. 

26 

Deformity 

Enucleation,  left 
{evidement) 

Solid  adenoma,  size  of  walnut 

R. 

73 

March  18 

Mrs.  M. 

29 

Deformity ; 
slight  dyspnoea 

Enucleation, 
right 

Cystic  adenoma ;  3i  in.  in  dia- 
meter (removal  through 
incision  2  in.  long) 

R. 

74 

April  22 

Alice  E. 

33 

Dyspnoea 

Enucleation,  left 

Solid  adenoma,  size  of  duck's 

egg ;  Ih  oz. 

Parenchymatous ;  lOA  oz. 

R. 

75 

April  22 

Hilkiah  AV. 

20 

Deformity ; 

Extirpation, 

R. 

dyspnoea 

right 

(Fig.  21) 

76 

May  14 

Mrs.  D. 

40 

Dyspnoea 

Enucleation,  left 

Parenchymatous ;  about  5  oz. 

R. 

77 

[June  3 

Beatrice  C. 

20 

Dyspnoea 

Enucleation, 
right 

Cystic  adenoma,  one-third 

solid,  size  of  duck's  egg ; 

partly  substernal 

R. 

78 

July  6 

Lucy  H. 

35 

Dyspnoea 

" 

Two  solid  adenomata,  size  of 

hen's  egg  and  cherry  resiiec- 

tively 

R. 

79 

July  13 

Rose  S. 

27 

Slight  dyspnoea 

Enucleation,  left 

Solid  adenoma,  size  of  duck's 
egg,  broken  up  and  removed 
through  incision  2:^  in.  long 

R. 

80 

July  22 

Caroline 

35 

Slight  dyspnoea ; 

Enucleation,  left 

Cystic  adenoma,  size  of  ban- 

R. 

W. 

going  abroad 

(ividement) 

tam's  egg,  two-thirds  solid 

81 

Sept.  7 

Martha  M. 

27 

Dyspnoea 

Enucleation, 

right 

Enucleation,  left 

Solid  adenoma,  size  of  walnut 

R. 

82 

Oct.  14 

Elizabeth 

35 

Great  deformity ; 

Solid  adenoma,  size  of  cocoa- 

R. 

T. 

discomfort ;  dys- 
noea  and  stridor 

nut;  5Jx4  in. ;  16  oz.  (Fig.  101) 

83 

Oct.  21 

Elizabeth 
B 

28 

Dyspnoea 

Enucleation 

{evidement) 

Solid  adenoma,  size  of  large 
walnut ;  partly  substernal 

R. 

(     349     ) 

GOITRE  BY  OPERATION  (EXTIRPATION  AND  ENUCLEATION). 

February  1894  and  January  1901. 


Remarks. 


Drainage ;  primary  imion 


Ko  drainage ;  primary  union 
Drainage ;  primary  imiou 


No  drainage ;  primary  union 
Drainage ;  primary  vmion 

No  drainage :  primary  union 
Drainage ;  primary  union 


No  drainage ;  primary  union 


No  drainage ;  slight  supei-flcial 
suppuration ;  healed  in  18  days 


Drainage ;  primary  union,  except 

in  track  of  tube  where  a  very 

small  sinus  remained  for  several 

months  and  then  healed 

No  drainage ;  primary  miion 


Drainage ;  primary  union 


No  drainage ;  primary  union 


99.6° 
100.2° 

99.2° 

99.4° 
100.0° 

100.4° 
99.4° 

102.8° 
99.6° 

100.4° 

99.8° 
100.8° 


101.0° 


99.6° 


100.6° 


99.6° 
100.6° 


a  o 


Oblique 


Oblique 
(Fig.  117) 
Oblique 


Trans- 
verse 


Oblique 


Trans- 
verse 


Oblique 

Trans- 
verse 
(Fig. 102) 

Trans- 
verse 


Mor- 
phine & 
cocaine 

only 
Chloro- 
form 


Mor- 
phine ; 
chloro- 
form 
for  skin 
incision 
only 
Mor- 
phine 
and  eu- 
caine 
Eu- 
caine 
only 
Mor- 
phine 
and  eu- 
caine 


Chloro- 
form 


Mor- 
phia & 
eucaine 


Latest  Report  (and  Source  of). 


July  1899.— Quite  well  (personal 

observation) 


May  1899.— Quite  well ;  fistula 
closed  (personal  observation) 


July  1899.— Quite  well  (personal 
observation) 

Ditto 

May  1899.— Quite  well  (letter) 


July  1899.— Quite  well  (personal 

observation) 
July  1899.— Quite  well  (Dr.  Per- 

ram,  AVliitchurch,  Salop) 
July  1899.— Quite  well  (Dr.  Wal- 

lis,  Leiston,  Sufi'olk) 
•July  1899.— Quite  well  (Dr.  Cross- 

key,  Lewes) 

July  1899.— Quite  well  (Dr.  Baker, 

Rushden,  Northamptonshire) 

July  1899.— Quite  well  (Dr.  Tan- 
ner, Farnham) 
July  1899.— Quite  well  (Dr.  Wal- 
lis,  Leiston,  Suffolk) 


July  1899.— Quite  well  (Dr.  Hulke, 
Deal) 


Jan.  1901. — Quite  well  (personal 
observation) 

Jan.  1901.— Quite  well  (letter) 


Jan.  1901. — Quite  well  (personal 
observation) 


July  29,  1890.— Quite  well  (per- 
sonal observation) 
Jan.  1901. — Quite  well  (personal 
observation) 
Remained  quite  well  in  all  respects 
until  May  1900,  when  she  died  of 
acute  pneumonia,  after  ten  days' 
illness 
Jan.  1901. — Cannot  be  traced 


t  Temperature  taken  every  four  houre. 


(     .S50     ) 

ONE  HUNDRED  CONSECUTIVE  CASES  OF  REMOVAL  OF 

Pofonncd  Inj  the  Anther  between 


Nov.  11 

Nov.  30 
Dec.  9 

Dec.  IG 

1900 
.Jan.  0 

.Jan.  11 
Jan.  18 

.Jan.  20 

Feb.  10 
Teb.  10 
Feb.  17 

Feb.  17 
March  16 

March  22 


April  9 
April  25 
April  27 

May  26 
May  26 

May  27 
.June  2 


Ellen  G. 

Miss  AA'. 
Annie  1*'. 
Sarah  S. 
Emma  M. 

Harry  N. 

Elizabeth 
D. 

Marion  E. 

Eleanor  G-. 
Marie  M. 
Emily  H. 


Elizabeth 

S. 

Rose  C. 


Mrs.  K. 


Elizabeth 

A. 
Emily  W. 

Dr.  K. 


Betsy  Z. 


Beatrice 
E. 


Dr.  M. 


Christine 
H. 


Oliief  Reason  for 
Operation. 


Dyspna'a 


Deformity ; 
dysphagia 

Dyspna'a 


Dyspnoja, 
dysphagia 

Dyspna-a 


Dyspna'a 

Bulk ;  discomfort 
and  deformity 


(.)l)eration. 


20  Slight  dysphagia ; 

"deformity; 

steady  growth 

Low  situation ; 

slight  dyspna>a 

Dyspna3a 


Dyspniea 


Low  situation ; 
slight  dyspnoea 

Dyspnoea ; 

deformity 


Dyspna-a 


Dyspna'a 
Deformity 


Occasional 
dyspnoea 


Deformity 


Deformity  and 
dyspnoea 


Dyspnoea  and 

leakage  from 

previous  tapping 

Deformity 


Enucleation,  left 


Enucleation, 
right  and  left 


Enucleation 
Enucleation,  left 


Enucleation, 
right 


Nature  of  Goitre. 


Extirpation, 

right 
Enucleation, 

right 

Enucleation,  left 


Enucleation, 
right  and  left 


E.xtirpation,  left 

Enucleation, 

pyramid 

Enucleation, 

right 


Extirpation 

through  right 

posterior  triangle 

Enucleation,  left 


Enucleation, 
right  and  isthmus 


Solid  adenoma,  size  of  hen's 
egg ;  partly  substernal 


Two  adenomata.   R.  solid,  size 
of  walnut.   L.  four-fifths  fluid, 

size  of  orange 
Cystic  adenoma,  size  of  chest- 
nut; very  deeply  seated  and  at 

the  back  of  the  gland 

Four  adenomata,  largest  solid 

and  size  of  walnut  and  sul)- 

sternal ;  very  deeply  seated 

Five  adenomata ;  all  solid ; 

largest,  size  of  tangerine  orange 


Solid  adenoma ;  3  oz. 

Solid  adenoma,  size  of  cocoa- 
nut  ;  16  oz.  (Figs.  55,  56) 


Cystic  adenoma,  size  of  hen's 


Cystic  adenoma,  size  of  egg ; 

partly  substernal 

Parenchymatous ;  dh  oz. 

Cystic  adenoma,  size  of  hen's 


Solid  adenoma,  size  of  turkey's 
egg 

Two  adenomata  ;  left  lobe;  size 
of  cocoanut  and  chestnut 
respectively ;  16  and  2  oz. 

Small  solid  adenomata ; 
deeply  seated 


Parenchymatous,  with  adeno- 
mata ;  11  oz. 
Cystic  adenoma  of  pyiamid, 
size  of  walnut  (Fig.  31) 
Cyst,  size  of  hen's  egg 


Cystic  adenoma,  size  of  hen's 

egg 

Parenchymatous,  with  adeno 

mata ;  about  5  oz. 


Large  cystic  adenoma  with 
thick  fibrous  and  calcified  wall, 

size  of  large  orange 
Solid  adenoma,  size  of  orange 


(     351      ) 

GOITRE  BY  OPERATION  (EXTIRPATION  AND  ENUCLEATION). 

February  1894  and  Januarij   1901. 


No  drainage ;  primary  union 


No  drainage ;  secondary  union ; 

slight  suppuration ;  wound  opened 

up  on  11th  day  ;  sinus  healed 

after  14  weeks 
Drainage ;  secondary  union  ; 
slight  suppuration ;  wound  par- 
tially opened  up  on  6th  day ;  pa- 
tient went  home  on  21st  day ; 
sinus  persisted  for  8  months ;  was 
twice  laid  open,  then  healed 
Drainage ;  primary  union 

No  drainage ;  primary  union 

Drainage ;  primary  union ;  was 

riding  a  bicycle  on  7th  day  after 

operation 

No  drainage ;  primary  union 

Drainage ;  primary  union 


No  drainage ;  primary  union 


100.6° 
99.6° 

100.6° 
100.8° 

99.4° 

99.4° 
99° 
99° 

99.6° 


100.2° 


99.6° 
99.4° 


99.4° 
99.8° 


L,.p3  o  o 
to  o  £"  '^ 


&ss 


s  <^ 


Oblique 


Trans- 
verse 


Oblique 


Trans- 
verse 

Trans- 
verse 
(Fig.  57) 

Trans- 
verse 


Oblique 

Trans- 
verse 
(Fig.  116) 
Oblique 

Trans- 
verse 


Mor- 
phia 

and  co- 
caine 

Chloro- 
form 


Oblique 

Trans- 
verse 
Oblique 


Trans- 
verse 
Vertical, 

in 
posterior 
triangle 
Oblique 


Trans- 
verse 


Latest  Report  (and  Source  of). 


Mor- 
phine 

and  co- 
caine 

Chloro- 
form 


Jan.  1901. — Quite  well  (personal 
observation) 


Ditto 
Jan.  1901.— Quite  well  (letter) 


Jan.  1901. — Quite  well  (personal 
observation) 

Jan.  1901. — Quite  well ;  remaining 
adenomata  have  undergone  some 
enlargement  but  caused  no  trouble 

(personal  observation) 

.Jan.  1901. — Quite  well  (personal 

observation) 

Ditto 


Jan.  1901  —Quite  well  (letter) 


Ditto 

April  1900.— Quite  well  (personal 

observation) 
Jan.  1901. — Quite  well  (personal 

observation) 

Jan.  1901.— Quite  well  (Dr.  Maund, 

Newmarket) 

Jan.  1901.— Quite  well;  left  vocal 

cord  in  cadaveric  position  but  voice 

natural  (personal  observation) 

Jan.  1901.— Quite  well  (letter) 


Jan.  1901.— Quite  well  (personal 

observation) 

Ditto 

Jan.  1901.— Quite  well  (letter) 


Ditto 

Jan.  1901. — Has  been  very  much 

better  for  the  operation  (Dr. 

Evill,  Barnet) 

Nov.  1900.— Quite  well  as  regards 

neck  but  is  suffering  from  thoracic 

aneurism  (letter) 

Jan.  1901.— Quite  well  (letter) 


t  Temperature  taken  every  four  hours. 


(      352      ) 

ONE  HUNDRED  CONSECUTIVE  CASES  OF  REMOVAL  OF 

Performed  hy  the  Author  between 


No. 

Date  of 
Opera- 
tion. 

Name. 

< 

Chief  Reason  for 
Operation. 

Operation. 

Nature  of  Goitre. 

105 

June  3 

Ann  C. 

69 

Dyspncea 

Enucleation  (re- 
section enuclea- 
tion), isthmus 
and  right 

Old  calcified  adenoma,  size  of 
an  orange  (Figs.  43,  44) 

K. 

106 

June  7 

Eliza  van  I. 

39 

Dyspnoea 

Enucleation,  left 

Cystic  adenoma,  one-tenth 

solid ;  size  of  hen's  egg ;  deeply 

seated 

E. 

107 

June  12 

Caroline  T. 

43 

Dyspnoea 

" 

Cystic  adenoma,  size  of  small 

orange ;  oue-ciuarter  solid ; 

deeply  seated 

E. 

108 

June  23 

Jane  "VV. 

23 

Dyspnoea 

Enucleation, 
right 

Cystic  adenoma,  size  of  walnut : 
two-thirds  solid ;  deeply  seated 

E. 

109 

June  23 

Emily  H. 

30 

Defoi-mity 

Enucleation,  left 

Solid  adenoma,  size  of  a  small 
oi-ange  (Figs.  114, 115) 

E. 

110 

June  28 

Mary  L. 

17 

Dyspncea 

Enucleation, 

right 
E.xtirpation. 

Cystic  adenoma 

E. 

111 

July  5 

Fanny  F. 

64 

Dyspncea 

Parenchymatous ;  10  oz. 

E. 

right 

(Fig.  94) 

112 

Julys 

Sarah  M. 

55 

Dyspnoea 

" 

Parenchymatous,  with  much 

fibrous  tissue ;  16  oz. 

(Figs.  49,  50,  51) 

E. 

113 

July  14 

Fanny  M. 

50 

Severe  dyspnoea ; 
malignancy 

Partial  extirpa- 
tion, left  and 
middle 

Spindle-celled  sarcoma ;  tum- 
our removed  size  of  apple ;  4  oz. 

E. 

114 

July  16 

Mrs.  G. 

39 

;  Dyspnoea 

Enucleation,  left 

Cystic  adenoma,  size  of  orange ; 
two-thirds  solid 

E. 

115 

Sept.  7 

Ellen  H. 

37 

Dyspncea 

Enucleation, 
right 

Three  cystic  adenomata,  lar- 
gest size  of  walnut 

E. 

116 

Sept.  8 

Elizabeth 
E. 

17 

Dyspnoea 

» 

Two  solid  adenomata,  largest 
substernal ;  size  of  goose's  egg 

E. 

117 

Sept.  15 

Elizabeth 
C. 

36 

Dyspnoea 

" 

Solid  adenoma,  size  of  goose's 
egg 

E. 

118 

Oct.  17 

Miss  A. 

36 

Deformity ; 
palpitation 

Enucleation,  left 

Cystic  adenoma,  size  of  hen's 
egg ;  mainly  solid ;  much 

fibrous  tissue 

E. 

119 

Oct.  20 

Eliza  H. 

52 

Bulk,  weight, 
and  deformity 

Extirpation, 
right  and  middle 

Old  parenchj-matous  goitre ; 
weight  of  tumour  after  re- 
moval, 49  ozs. 
(Figs.  34,  35,  36) 

E. 

120 

Oct.  25 

Mi-s.  L. 

39 

Bulk,  weight, 
and  deformity 

Enucleation, 
right 

Cystic  adenoma,  size  of  large 
orange 

E. 

121 

KoY.  3 

Grace  B. 

35 

Dyspnoea 

Enucleation 

Cystic  adenoma,  size  of  hen's 

E. 

122 

Nov.  10 

Ellen  L. 

33 

Dyspncea  and 
and  ansmia 

Enucleation,  left 

egg 

Solid  adenoma,  size  of  a 

turkey's  egg 

E. 

123 

Nov.  10 

Jemima  S. 

43 

Dyspnoea 

Enucleation, 
right 

Solid  adenoma,  with  much  fib- 
rous tissue ;  size  of  orange ; 
very  adherent 

E. 

124 

Nov.  10 

Albert  D. 

18 

Deformity;  dis- 
comfort; slight 
dyspnoea 
Dyspnoea ; 

Cystic  adenoma,  size  of  small 
orange ;  mainly  fluid 

E. 

125 

Nov.  26 

Miss  S. 

32 

Enucleation,  left 

Cystic  adenoma,  with  hsemor- 

E. 

discomfort 

hage ;  four-fifths  solid ;  size  of 
a  lemon 

126 

Dec.  8 

Gertrude 
A. 

29 

Dyspncea 

Enucleation, 
right 

Solid  adenoma,  size  of  duck's 

egg ;  contained  also  a  cyst  size 

of  cheiTy 

E. 

(     353     ) 

GOITRE  BY  OPERATION  (EXTIRPATION  AND  ENLX'LEATION). 
February   1894  and  Janiumj  1901. 


Brainage ;  primary  union 


No  drainage ;  primary  union 
Drainage ;  piimaiy  union 

Xo  drainage ;  pruuary  union 
Drainage ;  primary  union 


If  o  drainage ;  primary  union 


Drainage ;  secondaiy  union ;  slight 
suppuration  for  about  a  fortnight; 

left  hospital  on  17th  day  after 

operation :  wound  almost  healed 

Drainage ;  primary  union 


Jfo  drainage ;  primaiy  union 
Drainage ;  primary  imion 


2s  o  drainage ;  primary  imion 


99.6= 

99.8- 
99.2° 
99.4= 
100= 
100.0° 

100.8° 

100.8= 
99.4= 


100.8° 


No  drainage;  primary  union         100.4= 

i 
Drainage ;  primary  union  ini.G' 


101.4= 
101.4° 
99.8= 
100.8° 


S  s  Si;  I 


Trans- 
verse 

Mor- 
phia 
and  eu- 

Oblique 

came 
Chloro- 
form 

Trans- 

Trans- 

verse 

" 

Oblique 

(Fig.  95) 

Trans- 

verse 

Oblique 

„      ■ 

Trans- 

verse 
Oblique 

>' 

Trans- 

verse 

(T- 

shaped) 

Trans- 

verse 

Oblique 
(ellipti- 
cal) 
(Fig.  37) 
Trans- 

" 

verse 

Oblique 

„ 

Trans- 

vei-se 

" 

Latest  Report  (and  Source  of). 


.Jan.  1901. — Quite  well  (personal 
observation) 


Ditto 


.Jan.  1901.— Quite  well  (Dr.  Tol- 
putt,  Kettering) 

.Jan.  1901. — Quite  well  (personal 

obserN'ation) 

Ditto 

Ditto 

Dec.  1900.— Quite  well  (letter) 

•Jan.  1901.— Quite  well  (Dr.  Mar- 
shall, Bex-hill) 

Kov.  1900. — Ee-admitted  for  trach- 
eotomy and  died  soon  afterwards 
with  extensive  recurrence  (Fig.  78) 
Nov.  1900. — Quite  well  (personal 
observation) 
•Jan.  1901.— WeU :  still  several 
small  adenomata  in  both  lobes ; 

respiration  easy 

.Tan.  1901.— Ee-admitted  -svith  a 

small  sinus  which  soon  healed ; 

othenvise  well  (personal 

obsen'ation) 

Quite  well  on  lea^'ing  hospital  on 

9th  day :  quite  well  when  last  seen 

several  weeks  later  (Dr.  Ban-on, 

Ascot) 

Dec.  19C0. — Quite  well  (personal 

observation) 

Jan.  1901. — Quite  well  (Dr.  Image 
Buiy  St.  Edmunds) 


Dec.  1900.— Quite  well  (letter) 

Jan.  1901.— Quite  well  (Dr.  Eob- 

ertson,  &ospoi-t) 
Jan.  1901.— Quite  well  (Dr.  Raglan 

Tliomas,  Exeter) 
.Jan.  1901.— Quite  well  (Dr.  Mar- 
shall, Bexliill) 

Jan.  1901.— Quite  well  (pei-sonal 
obsei-vation) 

Jan.  1901.— Quite  well  (Dr.  Stack, 
Bristol) 

Jan.  1901.— Quite  well  (letter) 


t  Temperature  taken  every  four  hours. 


INDEX. 


Abscess  of  thyroid,  130-45 
Accessory  thyroid  vein,  268 
thyroids, 

anatomy,  12-13 
compensating  hypertrophy,  15 
Acute  goitre,  48 

Adenomata,transitiou into  cysts, 154-5 
Adenomatous  goitre, 
colour  of,  283 
cystic,  42-3 
enucleation  of,  280  et  seq. ; — versus 

extirpation,  337 
evidement  of,  294 
fatal  case  of  removal  of,  311 
foetal,  39-42 
malignant, 

diagnosis    from    innocent,    98, 

199,  211,  221 
results  of  operations  on,  221-2 
Air  and  sunshine,  supposed  effect  on 

goitre,  53-5 
Amputation  of  goitre,  279 
Amyloid  goitre,  48 

Anassthetic,  use  of,  in  thyroid  opera- 
tion, 257-60,  295-7 
Aneurism,    diagnosis    from     thyroid 

tumour,  92-96 
Animals, 

cretinism  in,  67 
goitre  in,  67 

symptoms    following    removal    of 
thyroid  in,  320 
Antisepsis — versus  asepsis,  in  thyroid 

operations,  215-16,  270-1 
Arteries, 
carotid, 

relation — to  thyroid,  5 — to  thy- 
roid tumour,  87-9,  92, 140,  204 
— to   trachea,    in   malignant 
goitre,  224 
resection  of,  218 
inferior  thyroid, 
ligature  of, 

danger  to  sympathetic  in,  302 
history  of  operation  241-  3 


Arteries,  inferior  thyroid,  ligature  of, 
in,  extirpation,  268-9 

in,  resection-extirpation,  278 
method,  243-4 
recurrent     haemorrhage    from, 

305 
relation  to  thyroid,  5,  9 
superior  thyroid, 
ligature  of, 

history  of  operation,  241-3 
in  extirpation,  267-8 
in  resection,  275 
in  resection-extirpation,  278 
method,  243 
relation  to  thyroid,  8-9 
relation   to   enlarged    thyroid, 
89,  92 
thyroidea  ima,  9 
Aseptic  treatment,  value  of,  in  thyroid 

operations,  215-16,  270-1,  304 
Asphyxia,   due  to  congenital   goitre, 

15,  19      " 
Asthma,  simulating  goitre,  106 
Atmosphere,  relation  to  goitre,  51-2 
Atrophy  of  thyroid, 
in  cretinism,  26,  30 
in  myxoedema,  21-2 
senile,  20-1 
Atrophy  of  tracheal  wall,  114-16 
Austria,  goitriferous  waters  in,  65-6 

Basedow's  disease    {See  Exophthal- 
mic Goitre) 

Bedfordshire,  goitre  in,  51,  58 

Belladonna,  use  of,  in  Graves"s  disease 
186 

Blood,  expectoration  of,  in  malignant 
goitre,  206 
hsematozoa  in  goitrous,  69 

Blood-vessels  [Sec  under  Arteries  and 
Veins) 

Bloodless  enucleation,  292-3 

Bohemia,  goitre  in,  65 

Bone,  growths  secondary  to  malignant 
goitre  in,  209 


356 


INDEX. 


Brachial  plexus  (.SV(  under  Nerves) 
Brain,  relation  to  exojphtbalmic  goitre, 

178 
Brecknockshire,  goitre  in,  63 
Bromine,  use  of,  in  Giaves's  disease, 

187 
Bronchitis, 

causing  death  f;fter  thvroid  ojoera- 

tion?,  208,  225,  334 
complicating  exothyropexy,  248 
dyspnci'a  from,  120 
goitre  i-imulating,  106 
Bronchocele  (/Vfc  Goitre) 
Buckinghamshire,  goitre  in,  51 

Cachexia  strumipriva 

avoided  by  compensating   hyper- 
trophy     of      thyroid,      15,     31, 
324-5 
due  to  absence  of  thyroid,  14,  188, 

320,  324 
due  to  ligature  of  thyroid  vessels, 

190 
history  of,  318-22 
Horsley's  experiments,  320 
relation  to  myxedema,  320 
symptoms,  323-4 
temporary,  326-7 
treatment,  327 
Cachexia  thyreopriva,  318 
Calcareous  rocks,  distribution  of  goitre 

on, 55-6,  58-63,  64 
Cambrian  rocks,  distribution  of  goitre 

on,  63,  64 
Cancer,  condition  of  thyroid  in,  35 
Carboniferous   rocks,  distribution  of 

goitre  on,  62-4 
Carcinoma  (.SVe  Malignant  Disease  of 

Thyroid) 
Cardiac  nerves,  injury  of,  in  thyroid 

operation,  315 
Carotid  artery  (See  under  Arteries) 
Cellulitis,       complicating        thyroid 

operations,  307 
Cervical  lymphatics, 

abscess  of,  simulating  goitre,  75 
inflammation  of,  simulating  thy- 
roiditis, 134 
Cervical  plexus  {8cc  under  Nerves) 
sympathetic  (Sec  under  Nerves) 
Chalk  districts,  goitre  in,  58 
Chloroform,    fatkl   cases   of    thyroid 

operation  under,  296 
Cholera,  causing  thyroiditis,  131 
Chronic     inflammation     of     thyroid, 
136-7 

simulating  sarcoma,  199 
Climate,  influence  on  goitre,  50-2 
Coal  measures,  goitre  on,  62,  64 
Cocaine, 

effect  of  injection  into  eye,  190-1 


Cocaine,  use  of,  in  thyroid  operations, 
259-60 
dose,  260 
Colloid  goitre,  46-7 
Colloid  secretion,  12 

abnormal  accumulation,  122, 152-3 
absence  of,  in  exophthalmic  goitre, 
180,  187-8 
in  myxcedema,  21-3 
absorption  of,  314-15 
character    of,   in   cystic    disease, 
161-2,  167,  169,  172-5 
in  exo{.hthalmic  goitre,  178 
diminution  of,  253-5 
in  senile  atrophy,  20 
relation  to  fat  formation,  35 
Congenital  goitre, 
cases  of,  15-16 
in  animals,  17-18 
treatment,  18-19 
sarcoma,  198 
Cough,  in  tracheal   obstruction,   102, 

132 
Cretaceous  formation  and  goitre,  56, 

58-9 
Cretinism, 

atrophy  of  thyroid  in,  26,  30 
cause  of,  14,  320 

connection  with  cachexia  strumi- 
priva, 320 

endemic  goitre,  24,  26,  29-30 
myxcedema,  23-4,  320 
enlarged  thyroid  in,  25-6,  30 
fatty  tumours  of,  27-8 
in  animals,  67 

sporadic  {See  Sporadic  Cretinism) 
treatment,  30 
Cricoid  cartilage,  division  of,  in  extir- 
pating goitre,  270 
Crystalline  rocks,  goitriferous  waters 

in,  66 
Cysts, 

simulating   thyroid    enlargement, 

73,  75 
thyroid  of, 

adenoma  [Sec  that  name) 

classification,  156-7 

colour,  283 

description,  37-8 

developmenr,  154-5 

diagnosis       from       malignant 

goitre,  210 
hEemorrhagic,  46,  123 
hydatid  (See  Hydatid  Cysts) 
intra  cystic  growths,  164 

h^morrliRge,  158-60 
origin  of,  152-6 
position  of,  82-3,  84-5,  91 
papilliferous  {See  Papuliferous 

Cysts) 
structure,  160-4 


IN13EX. 


357 


Cysts,    thyroid   of,    suppurating   {!<ee 
Suppurating  Cysts) 
treatment, 
enucleation,  280  et  scq. 
incision,  239-40 
injection,  237-9 
seton,  240-1 
tapping,  231-2 

Death, 

during  thyroid  operation,    causes 

of,  and  cases,  295-9 
following  thyroid  operation, 
causes  of,  314-16,  334-5 
symptoms,  310-14 
from  dyspnoea  {See  Dyspnrea) 
Derbyshire,  goitre  in,  52,  61-5 
Devonian    and     old    red    sandstone, 

goitre  in  region  of.  63-4 
Devonshire,  goitre  in,  58,  63 
Diarrncea,  in  Graves's  disease,  183 
Digitalis,  administration  in  Graves's 

disease,  186 
Dysphagia, 

due  to  goitre,  102-3 

tliyroiditis,  132 
following  exothyropexy,  248 
treatment  of,  226 
Dysphonia, 

due  to  goitre,  102 

extirpation  of  goitre,  301 
Dyspnoea  in  goitre, 

analytical    taole   of    fatal   cases, 

126-9 
causes   of,    97,    102,    107-20,    132, 

295-9,  306 
influence  of  age  and  sex  on,  121-3 
occasional  effect  of  exothyropexy, 

248 
relief  of, 

by  resection  of  isthmus,  251-3, 

255-6,  278 
results  of  oper-ations  in,  336 
varieties  of  goitre  producing,  15, 19, 
91,  92,  105-6,  122-25,  185 
Dyspnoea  in    malignant  goitre,    205, 
207,  208,  214,  219 
relief  of,  222-6 

ECHINOCOCCUS,  165 

Electrical  t/eatment  of  Graves's  dis- 
ease, 187 

Endemic  goitre, 

allegea  causes,  52-71 

basis  of  European  statistics,  50 

connection  with  cretinism,  24,  26, 

29-30 
geographical  distribution,  51-5 
geological  distribution,  55-65 
use  of  term,  48 


England, 

distribution  of  goitre  in,    15,  16, 

34,  51-4,  58-65,  83,  92,  93,  95 
geological   formation   and  goitre, 
57-63 
Enucleation  {See  Intra-glandular  Enu- 
cleation) 
Epidemic  goitre,  48 

cause  of,  66 
Essex,  goitre  in,  58 
Eucaine,  use  of,  in  thyroid  operation, 

259-60 
Evidement,  293-4 
Exophthalmic  goitre, 

diagnosis  and  symptoms,  92.  101, 

183-6 
dissimilarity   to    other    forms   of 

goitre,  44,  49 
distribution,  176-7 
fatal  symptoms  following  removal, 

31.3-14,  316 
influence  of  age  and  sex  on,  176 
morbid  anatomy,  31,  47-8,  179-82 
pathology,  178 

prognosis  without  operation,  194 
simulating  malignant  disease,  210 
treatment, 

medical,  186-7 
table  of  result^,  194-5 
surgical,  187-96,  243,  245,  249 
Exophthalmos, 

cause  of,  in  Graves's  disease,  182-3 
effect  of  operation  on  sympathetic, 

190-3 
from  injection  of  cocaine  into  eye, 

190-1 
unilateral,  184 
Exothyropexy, 

complications  in,  247-9 
for  congenital  goitre,  19 
for  exophthalmic  goitre,  189-90 
history  and  method,  244-7 
mortality  after,  249 
Extirpation, 

after  treatment,  273-4 
angesthetic,  use  of,  in,  258-60 
compared  with  exothyropexy,  245 
with  re.'^ection  of  isthmus,  256 
complications  of, 

cachexia  strumipriva   {See  that 

name) 
hemorrhage,  primary,  299 
recurrent,  305-7 
secondary,  304 
injury  of  nerves  in,  300-2,  338 
of     surrounding    btruotures, 
302-4 
late  paralysis  of  vocal  cord,  316 
rapid    pulse  aod    restlessness, 

310-16 
sepsis,  307-10 


358 


INDEX. 


Extirpation,  complications  of,  sudden 
death,  295-9 

tetany,  316-17 
difference    between     enucleation 

and, 257-S 
method  of  operation, 

blood-vessels,  ligature  of,  264, 

267-9 
dissection    from     surrounding 

structures,  266-70 
drainage  of  wound,  271,  274 
incision  of  skin,  260-4 
infra-byoid  muscles,  treatment 

of,  262,  264-6 
position  of  patient,  260 
of  exophthalmic  goitre,  lSS-9 
statistics  of  results, 
partial  extirpation, 

causes  of  death  (table),  334 
of  exophthalmic  goitre,  188-9 
of  innocent  goitre,  189,  216, 
329-42     (-S'fc   also   Appen- 
dix) 
total  extirpation, 

of  malignant  goitre,  216-22 
total,  258 

of  exophthalmic  goitre,  188 
of  malignant  goitre,  212-22 
Eye,  contraction  of  pupil  from  goitre, 
99-100 

Fat  formation,  relation  to  thyroid,  35 
relation  of  Graves's   disease  to. 
182-3 
Fatty  degeneration  of  trachea,  due  to 
goitre,  114,  115 
tumours,  of  cretinism,  27-8 
Fibrous  goitre,  43-4,  96,  125 
Fistula    after    injection    of    goitre, 

136-7,  238-9 
Foetal  adenoma  {See  Adenoma) 
"Formes  frustes,"  184,  194 
France, 

distribution  of  goitre  in,  52,  199 
exothyropexy  in,  244 
goitriferous  waters  in,  64,  68 

Gatjlt,  distribution  of  goitre  on,  58-9 
Geological     formations,      connection 

with  goitre,  55-69 
Glamorganshire,  goitre  in,  52,  62 
Glottis,  dyspnoea  due  to  oedema  of, 

119 
Gloucestershire,  goitre  in,  52,  60,  61, 

93 
Glycosuria,  in  Graves's  disease,  183 
Goitre, 

condition  of  blood  in,  69 
diagnosis  by  dyspncea,  105-29 
physical  signs,  72-96 


Goitre,  diagnosis  by  pressure  on   sur- 
rounding structures,  96-104 
diseases  simulating,  73-8,  92-4 
distribution  of,   50-71      (See   also 

under  Various  Countries) 
in  animals,  67-9 
inflammation  of.  130-45 
influence  of  pregnancy  on,  33-4 
of  puberty  on,  34 
of  sexual  excitement  on,  34 
meaning  and  use  of  word,  36 
mixed  forms,  44 
relation  to  fat  formation,  35 
simulating  asthma,  106 
treatment, 

division  or  resection  of  isthmus, 

250-6 
exothyropexy,  244-9 
extirpation  (Sec  that  name) 
incision,  232-3 
injection,  233-41 
intra-glandular        enucleation 

{See  that  name) 
ligature    of    thyroid    arteries, 

241-4 
non-operative,  227-30 
resection,  275-9 
seton,  240 
tapping,  231-2 
tracheotomy  {See  that  name) 
varieties,  36-48 
scoops,  284 
wells,  67 
Graves's   disease    {See   Exophthalmic 

Goitre) 
Greensand,  lower,  65  ;  upper,  58-9 
Gummata  of  thyroid,  149-51 

Hampshire,  goitre  in,  58 
Hemorrhage, 

into  malignant  goitre,  209 
primary,  avoidance  of,  in  resection 
of  gland,  276 
arrest  of,  in  enucleation,  286-8, 
299-30 
in  exothyropexy,  247-8 
in  extirpation,  299 
recurrent,  after  thyroid  operation, 

305-7 
relation  of  pregnancy  to,  34 
secondary,    after    thyroid    opera- 
tion, 304 
Hfemorrhagic  cvst,  155-60 

goitre,  46,  123 
Heart,  rapidity  of,  in  Graves's  disease, 

183-5 
Heredity  of  goitre,  70-1 
Herefordshire,  goitre  in,  16 
Hertfordshire,  goitre  in,  58 
Hilus  of  thyi'oid,  5 
Hydatid  cysts,  118-9,  165-75 


INDEX. 


359 


Hyoid  bone,  relation  to  enlarged  thy- 
roid, 84,  85 
Hypertrophy  of  thyroid,  31-5 

compensating,  31,  166,  324-5,  336 
restriction  of  term,  31 
Hypoglossal  nerve,  wound  of,  in  ex- 
tirpation, 302 


Idiopathic  inflammation,  130-1 
Igneous  rocks,  distribution  of  goitre 

on,  56,  63,  64 
Incision 

of  cystic  goitre,  239-40 
of  skin,  in  extirpation,  260-4 
Indian  method  of  curing  goitre,  229-30 
Inferior   thyroid   {See  under  Arteries 

and  Veins) 
Inflammation  of  thyroid,  130-45 
Infiltrating  fibroma,  138 
Infra-hyoid  muscles 

in  relation  to  extirpation  of  goitre, 

262,  264-6 
relation  to  thyroid  tumour,  86-7 
suture  of,  271 
Injection, 

cystic  goitre,  of,  237-9 
in  thyroiditis,  135 
parenchymatous   goitre,    of,    232- 
37 
Intermarriage,  relation  to  goitre,  70 
Internal     jugular     vein     {See     under 

Veins) 
Intra-cystic  hfemorrhage,  231 
Intra-glandular  enucleation, 
after  injection,  239 
cases  suitable,  281-2 
compared  with  intra-capsular  and 

resection-enucleation,  292 
complications, 

haemorrhage;  primary,  299-300 

recurrent,  305-6 
sepsis,  307-10 
sudden  death,  295-8 
difference  between extirpationand. 

257-8 
history  of,  280-1 
injury  to  recurrent  nerve  in,  339 
method  of  operating,  282-8 
modifications, 

bloodless,  292-3 
evidement,  293 
intra-capsular,  292 
resection-enucleation,  288-92 
of  innocent  and  malignant  goitre, 

212 
recurrence  after,  336-7 
results    and    mortality   statistics, 

329-34  {See  also  Appendix) 
unsuitability      in      exophthalmic 
goitre,  188 


Iodine, 

injection  of,  in  cystic  goitre,  237-9; 
in  parenchymatous,  228-9,  233-7 
use  of,  in  Graves's  disease,  186-7 

Iodoform     solution,      injection,     for 
parenchymatous  goitre,  237 

Iron, 

perchloride  of,  injection  in  cvstic 

goitre,  237-9 
relation  to  goitre,  65,  67 
use  of,  in  Graves's  disease,  187 

Isthmus  of  Thyroid, 
absence  of,  14 

compensating  hypertrophy,  325 
division  of,  in  extirpation,  250-6, 

270 
enlargement  of.  81-2,  112-13 
excision  of,  fatal  case  of,  313 
in  resection  extirpation,  278 
position  and  relations  of,  1-2 
relation  to  tracheal  compression. 
251-3 

Italy, 

distribution  of  goitre  in,  53 
goitriferous  waters  in,  68-9 

Jaboulat's  operation,  190-1 
Jurassic   formations   and   goitre,  56, 
59-61,  66 


Kent,  goitre  in,  58 

Kidneys,  hydatid  cyst  in,  166,  172 

Koenig's  tracheotomy  tube,  225 

Lakynx, 

displacement  by  goitre,  101 
perforation  by  goitre,  118 
relation  to  thyroid,  3-4,  6-8 

to  enlarged  thyroid,  72-3,  76-7. 
82,  85, 113 
rupture  of  abscess  into,  119 
total    extirpation    in    a    case    of 
malignant  goitre,  214 
Laryngeal  diseases, 

simulating  goitre,  73-4 
thyroiditis,  134 
Lias  formation,  distribution  of  goitre 

on,  60-1 
Ligature. 

of  gland  substance  in  resection  of 

goitre,  276 
of  thyroid  arteries, 

for  exophthalmic  goitre,  190 
for  innocent  goitre,  241-4 
Lime  salts,  relation  to  goitre,  64-5, 

67,  68 
Limestone  districts     {See  Calcareous 

Rocks) 
Lincolnshire,  goitre  in,  15,  83 


360 


INDEX. 


Liver,  hydatid  cvst  of,  166,  16S,  172. 

173 
Longs. 

growths   secondary  to   malignant 

goitre  in,  206,  209 
sepsis      following      tracheotomv, 
225 
Ljmph  glands,  involved  in  malignant 

goitre,  205-6 
Lymphatics, 
of  thyroid,  11 

tumonrs  of,  diagnosis  from  thyroid 
tumour,  S3,  85-6 
Lvmpho-sarcoma.   simulating  goitre. 

"77-S 
Lyons,  exothyropexy  at,  244-5 

Magnesium  salts,  relation  to  goitre, 

64-5.  67.  68 
Magne!-ian  limestone  districts,  goitre 

in,  61-2 
Malaria,  a  causa  of  thyroiditis,  131 
Malignant  cysts,  contents  of,  160 
Malignant  disease  of  thyroid, 
adenoma  (Sec  that  name) 
death,  causes  of  in,  208-10 
diagnosis,  8S,  97-101,  199-206 
from  adenoma,  199 

chronic  inflammation,  199 
exophthalmic  goitre,  210 
innocent  cyst,  210 
parenchymatous  goitre,  210 
duration  of,  206-8 
influence  of  age  and  sex  on,  197-8 
papuliferous      cysts      (>'^-f      that 

name) 
treatment, 

by  extirpation, 

comj)lications,  213-14,  218 
danger  of  recurrence,  2 1 3-1  -! , 

219-21 
method,  21.5-16 
mortality  statistics,  216-21 
prognosis,  216 
palliative, 

incision,  223-4 
partial  extirpation,  222-3 
tracheotomy.  224-6 
varieties  of.  210-12 

relative  frequency  of  sarcoma 
and  carcinoma.  198-9 
Manubrium  of  the  sternum,  complica- 
tion iu  substernal  goitre,  248 
Median  goitre.  112-13 
Mediastinitic,  133,  209 
Menstruation,  enlargement  of  thyroid 

during.  32 
Mercurv  oiLtment,  use   of  in  goitre, 

229-30 
Micro-organisms,  in  goitre-producing 
water,  65-6 


Middle    thyroid    vein      (.See     under 

Veins) 
Middlesex,  goitre  in,  58 
Mikulicz's    resection      {Sc      Resec- 
tion) 
Millstone  grit,  62,  64 
Molasse,     geological    structure    and 

goitre,  56,  66 
Morphia,   use    of,    in    operation    on 

thyroid,  260 
Mountainous  districts,  goitre  in,  51-3 
Mountains,  geological  structure  and 

goitre,  55-6 
Murmur  in  thyroid  tumour,  93-5 
Muscles       (.SV-e       also      Infra-hyoid, 
Scalenus     anticus,     and      Sterno- 
mastoid) 
relation  to  thyroid,  5,  6,  8 
to  enlarged  thyroid,  85-7 
Muscular  exertion,  relation  to  goitre, 

69,  70 
Myxcedema, 

atrophy  of  thyroid  in,  21 

cause  of,  14,  320 

occasional  enlargement  of  thyroid, 

22 
relation  to  cachexia  strumipriva, 
320 

cretinism.  23-4,  320 
fat  formation,  35 
treatment  of,  22-3 

Nerves. 

brachial  plexus,  involved  in  thy- 
roiditis, 132 
pressure  of  goitre  on,  101 
cardiac,  injury  of,  in  thyroid  opera- 
tion, 315 
cervical  plexus,  involved  in  thy- 
roiditis, 132 

pressure  of  goitre  on,  101 
cervical  sympathetic. 

fatal  svraptoms  following  divi- 
sion", 313,  315 
involved    in    thvroid    tumour. 

99-101 
operations  on,  in  exophthalmic 

goitre,  190-4 
relation  to  exophthalmic  goitre, 

178 
wound  of,  in  extirpation,  302 
involved  io  chronic  inflammation, 

13S,  140 
of  thyroid  gland,  11 
recurrent  laryngeal. 

compression  by  scar.  316,  338 
danger  to.  in  extirpation,  300-1 
dangerto,  in  removal  of  hydatid, 

171 
dvspnoea,  due  to  irritation  of, 
'116-18.  295-6 


INDEX. 


361 


Nerves,   recurrent,    effect   of    injury, 
337-9 

in  relation  to  ligature  of    in- 
ferior   thyroid    artery,    269, 
270 
involved  in  chronic  inflamma- 
tion, 138,  140 
involved  in  thyroiditis,  132 
protection     of,     in     resection, 

275-6 
protection     of,     in     resection- 
extirpation,  275-6 
relation  to  thyroid,  5-6,  8 

thyroid  tumour,  97-9 
vagus,  302 
Nervous    symptoms,  in    Graves'  dis- 
ease, 183,  185 
Norfolk,  goitre  in,  58 
Northamptonshire,  goitre  in,  54,  60 
Northumberland,  goitre  in,  63 
Norvi'ay,   scarcity  of  goitre  in.  52-3, 

reason  of,  55 
Nottinghamshire,  goitre  in,  61 

(Edema, 

of  face  and  arm,  from  goitre.  97 
of  glottis, 

causing    death     in    malignant 

goitre,  210 
dyspnoea  due  to,  119 
in  thyroiditis,  133 
ffisophagus, 

infiltration  in  chronic   inflamma- 
tion, 140 
injury  in  thvroid  ooeration,  171, 

304 
partial  excision  in  thyroid  opera- 
tion, 218 
pressure  from  goitre,  102-4  ;  from 

inflamed  thyroid,  132,  134 
relation  to  tbyroid,  6,  7  ;  import- 
ance of  in  extirpation,  269-70 
thyroid  fistula  opening  into,  137 
Oolite  rock,  distribution  of  goitre  on, 

59-60,  65 
Operative  myxedema    {See   Cachexia 
strumipriva) 

Palaeozoic  formation  and  goitre.  56, 

61-3 
Papuliferous  cysts, 

description,  164,  211-12 

treatment,  221-2. 
Parathyroids,  13 
Parenchymatous  goitre, 

cause  of  enlargement  of  gland  in, 
36,  253-4 

consistency,  96 

description,  36-7 

dyspnoia  from,  109,  122-3,  126-7 

rapid  enlargement  of,  117,  122-3 


Parenchymatous     goitre,      shape    of 
compressed  trachea  in,  109 
symptoms  and  diagnosis  (.See  goi- 
tre, diag. ) 
diagnosis   from   exophthalmic, 

179-80,  184 
diagnosis  from  malignant  dis- 
ease, 210 
diagnosis  from  thyroiditis,  134 
symptoms  of  death  following  re- 
moval, 312-13,  316 
treatment  {See   Goitre,  Treatment 
of) 
Perchloride  of  iron,  injection  in  cystic 

goitre,  237-9 
Permian  rocks,  goitre   in   reeion  of, 

61-2 
Pharynx, 

injury  to,  in  removal  of  goitre,  304 
involvement  of  muscular  wall,  202 
penetration  in  thyroiditis,  133-4 
penetration  by  malisrnant  growth, 

202-3 
pressure  of  goitre  on,  103-4 
pre-sure  of   inflamed  thvroid  on, 

132 
relation  to  thyroid,  6,7;  import- 
ance of,  in  extirpation.  269-70 
Phthisis,  condition  of  thyroid  in,  35 
Pleura,  injury  in  thvroid  operation, 

303 
Pneumonia,    following    tracheotomy. 

225 
Post-tertiary   formations,  absence  of 

goitre  on,  56 
Potash  salts,  relation  to  goitre,  68 
Pregnancv,  relation  to  thvroid,  32-4, 

123 
Puberty,  relation  to  thyroid,  34  ;   to 

fatal  dyspncea,  122-3 
Puerperal  fever,  thyroiditis  in,  131 
Pulsation  of  thyroid  tumour,  92-6 
Pulse,  rapid,  following  thyroid  opera- 
tion, 
causes  of,  314-16 
danger  of,  fatal  cases,  310-14 
Pyaemia,  causing  thyroiditis,  131 
Pyramid  of  Lalouette,  3-4 
tumour  of,  84 

Eaixfall,  influence  on  goitre,  51 
Eecurrent  laryngeal  nerve  {See  under 

Nerves) 
Kesection, 

advantages,  279 
description,  275-6 
enucleation,  288-92 
extirpation,  advantages,  279 
compared  with  resection,  279 
description,  278-9 
results,  276-8 


362 


INDEX. 


Restlessness  following  thyroid  opera- 
tion, 

causes  of,  314-16 

danger,  .110-14 
Rheumatic  thyroiditis,  130-1 

Salzburg,   goitriferous    waters    at. 

65-6 
Sandstone  districts,  goitre  in,    55-6, 

61,  63 
Sarcoma  {Sir  Malignant  Disease) 
Scalenus  anticus  muscle,  in  relation  to 

ligature  of  thyroid  artery,  269 
Scar,  after  thyroid  operation,  262-3, 

342 
Scotland,  scarcity  of  goitre  in,  52 
Sepsis,    danger    of    and    treatment, 

307-10 
Seton    method    of    treating    goitre, 

240-1 
Sexual  excitement,   relation  to  thy- 
roid, 34 
Silurian  rocks,  goitre  on,  63,  64 
Skin, 

condition  in  cachexia  strumipriva. 
323 

in  Graves's  disease,  183 
incision  of,  in  extirpation,  260-4 
involvement     of,     by     malignant 

goitre,  205 
spontaneous     ulceration.      140-2. 
305 
Soda,   salicylate,   use  in  thyroiditis, 

135 
Sodium  salts,  relation  to  goitre,  67, 

68 
Somersetshire,  goitre  in,  16,  59-60,  63, 

95 
Sporadic  cretinism, 

distinguished  from  endemic,  27-9 
due  to  absence  of  thyroid,  24,  25 
Sporadic  goitre,  use  of  term,  48 
Staffordshire,  goitre  in,  63 
Sterno-mastoid  muscle, 

in  relation  to  extirpation  of  goitre, 
260,  262 
to  ligature  of   inferior  thyroid 
artery,  243-4,  269 
relation  to  thyroid  tumour,  86-7 
Sternum,  relation  to  thyroid  tumour, 

8,  88-92,  113 
Submaxillary,  tumour  of,  simulating 

goitre,  S3 
Substernal  goitre, 

diagnosis  from  aneurism,  93 
position  of,  89-91 
relation  to  fatal  dyspnoea,  124-5 
Suffocating  goitre,  48 
Suffolk,  goitre  in,  58 
Sunshine  and  air,  supposed  eft'ect  on 
goitre,  53-5 


Superior  thyroid   {See  under  Arteries 

and  Veins) 
Suppurating  cyst, 

asphyxia  due  to  rupture  of,  119 
penetration     into     trachea     and 

pharynx,  133-4 
treatment,  135 
Suppuration, 

due  to  injection,  234.  2  iS 
into  trachea  after  thvroid  opera- 
tion, 309-10 
Surrey,  goitre  in,  58,  59 
Suspensory  ligament  of  thyroid,  8 
Sussex,  goitre  in,  58,  59 
Switzerland, 

distribution  of  goitre  in.  15,  51-4, 

91  /(. 
geological   structure   and   goitre, 

55-6 
goitriferous  waters  in,  64-7 
Sympathetic  nerve  (.See  Cervical  sym. 

under  Nerves) 
Sympathicotomy,  190 
Syncope,    in    goitre    operation,    48, 
" 148-51 

Tapping  of  cystic  goitre,  231-2 
Temperature, 

after  extirpation  and  enucleation 

{See  Appendix) 
in  Graves's  disease,  183 
rise  after  exothyropexy,  247 
Tertiary  rocks,  goitre  in  region  of,  56, 

57-8,  64 
Tetany,  complicating  thyroid  opera- 
tion, 316-17 
Thymus, 

administration     of    preparations, 

186 
enlargement  in    Graves's  disease, 
183 
Thyroid  gland, 

absence  of,  effect  on,  24,  25,  317- 

318,  320,  324 
absorption      from      pressure     of 

hydatid,  166 
administration  of  extract,  23,  30, 

186.  228-9,  327 
atrophy,  20-30 
blood-vessels,  8-10 

ligature  of.  190,  267-9 
congenital  diseases,  15-19 

malformations,  14-15 
cystic  disease  {See  Cysts) 
disease  of  {See  Goitre) 
extirpation,  257-70  {See  also  this 

name) 
hypertrophy,  31-5,  166 
inflammation,  130-45 
influence  of  menstruation,  32 
pregnancy,  33-4 


INDEX. 


363 


Thyroid  gland,  influence  of  puberty,  34 
sexual  excitement,  34 
innervation,  11 
isthmus,  1-2 
lobes  of,  1,  3-4 
lymphatics,  11 
operations   on,   for   exophthalmic 

goitre,  187-90 
relations,  5-8 
structure,  11 

syphilitic  disease  of,  148-50 
tubercle,  146-8 
variations  in  human,  34-5 
weight  of, 

congenitally  diseased,  16 
normal,  1 

relative  weight  in  old  age,  20 
Thyroidea  ima,  9 
Thyroidectomy  [See  Extirpation) 
Trachea, 

adhesion    of  thyroid  abscess  to, 

138 
altered    relation    to    carotid,    in 

malignant  goitre,  224 
collapse  of,  in  removal  of  goitre, 

304 
complication     in     exothyropexy, 

248 
compression,     causing      dyspnoea 
from  goitre,  16,  97,  102,  107-16, 
120,  253 
due  to  hydatids,  167,  172,  174 
displacement,  82,  101-2,  113,  203 
infiltration,  139-40 
injury  to,    in   removal   of   goitre, 

218,  302-3 
mucous   membrane    involved    by 

malignant  goitre,  201-2 
penetration    by    thyroid    abscess, 
133-4 
malignant     growth,      118-19, 
201-3,  208 
pressure  of  enlarged  thyroid,  72-3, 

74,  76-7,  132,  203 
relation  to  thyroid,  6,  7 
rupture  of  hydatid  into,  167,  172 
Tracheal  diseases  simulating  goitre, 

73-5 
Tracheal    wall,   changes    in,   due   to 

goitre,  113-16 
Tracheotomy, 

danger  of,  during  thyroid  opera- 
tions, 298 
in  exophthalmic  goitre,  198 
malignant  goitre,  224-6 
Tracheotomy,    danger  in,    parenchy- 
matous goitre,  256 


Tracheotomy,    danger     in,     primary 

chronic  inflammation,  145 
Traumatic  inflammation,  131-7 
Triassic  formation  and  goitre,  56,  61, 

66 
Tuberculous  goitre,  48,  146-8 
Tumours, 

of  thyroid  {See  Goitre,  varieties) 
simulating  goitre,  73,  76-8,  83 
Typhoid  fever,  thyroiditis  complica- 
ting, 130 

UmLATEEAL  goitre,  relation  to  fatal 

dyspnoea,  124 
Urticaria,  in  hydatid  cyst,  168-9 

Vagus,   wound    of,   in    extirpation, 

302 
Valleys,  prevalence  of  goitre  in,  53-5 
Variola,  causing  thyroiditis,  131 
Vascular  goitre,  47-8 
Veins, 

accessory  thyroid,  268 
inferior  accessory  thvroid,  10 

thyroid,  10,  278 
internal  jugular, 

relation    to     thyroid    tumoui', 

88-9,  96-7,  140,  204 
resection  in  goitre  operation, 
218 
ligature    of,   in  extirpation,   264, 

267-8,  275,  278 
middle  thyroid,  10,  268 
recurrent  haemorrhage  from,  305 
superior  accessory  thyroid,  10 
thyroid,  10,  267-8,  275,  278 
thyroidea  ima,  10 
Vocal  cords, 

effect   of  resection   of  goitre  on, 

277 
paralysis  of, 

after  thyroid  operation,  337-9 

cause  of  late,  316 

due  to  goitre,  97,  98,  201 

Wales,  goitre  in,  52,  62,  63-4,  94 
Warwickshire,  goitre  in,  60-1 
Water, 

microscopical      examination       of 

goitriferous,  65-6 
supply,    influence   on   goitre,    55, 
57,  62,  64-9 
Wealden  area,  goitre  in,  59,  65 

YOEEDALE  rocks,  62,  64 
Yorkshire,  goitre  in,   15,  16,   34,  58, 
59,  60,  61,  62 


INDEX   OF   NAMES 


Albeks,  172 
Albert,  2.34,  316 
Albevtin,  249 
Aldriuh-Blake,  84 
Alibert,  80,  81 
Atkinson,  16 

Bach,  19 

Baillagev,  50,  67 

Bankai'D,  240 

Barker,  212,  221 

Barlow,  131 

Batten,  97 

Battle,  142 

Battle  and  Jones,  217 

Baumann,  130 

Baumgarten,  148 

Beach,  24 

Berard,  244,  246,  247,   249,  302,  303, 

304 
Bergeat,  198,  217 
Berger,  194,  212,  221 
Berry,  E.  E.,  68 
BidweJ],  146 

Billroth,  78,  222,  241,  280,  302,  216 
Birch-Hirschfeld,  150 
Bircher,  50,  52,  56,  66,  67,  68 
Blanc,  249 
Blizard,  241 
Bock,  165 
Boechat,  255 
Boeckel,  210 
Boissou,  191,  192 
Bose,  292-3 
Bouchardat,  67 
Bouilly,  194 
Bowlby,  73,    88,     91,   124,   138,    139, 

311 
Boyd,  170,  175,  224,  298,  306 
Bramwell.  127,  302 
Braun,  216,  217 
Bruns,  115,  147,  148,  299,  322 
Bryant,  129 
Buchanan,  249 


Burckhardt,  280 

Buschi,  217 

Butlin,  84,  85,  159,  216 

Cakle,  68 
Carver.  93 
Chavier,  170,  175 
Chiari,  146 
Cloquet,  150 
Coates,  241 
Cock,  166,  175 
Colby,  15 
Comte,  160 
Cordua,  145 
Corley,  305 
Cramer,  214,  217 
Crawfurd,  178 
Crisp,  17 
Cruveilhier,  131 
Curling,  24,  27 

Dalrymple,  94 

Dardel,  165 

Davies,  51 

Davis,  217 

De  Ranee,  57 

Demme,  15,  108,  149 

Dewes  and  Heidenreich.  12-; 

Dixon, 165 

Dolerio,  194 

Downes,  241 

Drobnik,  242,  244 

Duquet,  165 

Eaele,  241 
Edmunds,  13,  191 
Edwards,  127 
Eminson,  15,  83 
Ewald,  217 

Fagge,  24,  25 
Eaure,  192 


INDEX   OF   NAMES. 


36c 


Federn,  194 
Fergusson,  93 
Ferrant,  173 
Florez  (Dr.  M.  Y.),  177 
Fraenkel,  151,  19i 
Francis,  93 
Frank, 217 
Furnivall,  73 
Fiirst,  149 

Gallozzi,  167,  173 
G-aucher,  106,  129 
Genevet.  19 
Gibb,  250,  252 
Gibbs,  127 
Gooch,  172 
Gottstein,  191 
Grasset,  69 
Gray,  93 
Greenfield,  178 
Guillemot,  249 
Gull,  320 
Gtinther,  241 
Gurlt,  165 
Guthrie,  131 

Hack,  194 

Hanau,  26 

Hartmann,  249 

Heidenreich.  133 

Heidenreich  and  Dewes.  123 

Henle,  165,  174 

Hicquet,  317 

Hirsch,  67 

Hochgesand.  217 

Hoffmann,  194 

Holthouse,  250 

Horsley.  317,  320 

Hovell,  238 

Hurry,  128 

Husson,  106 

Jaboulay,  192,  244,  245,  248,  249 

Jeannel,  144 

Jenks,  32,  34 

Jessop.  190-1,  332 

Jobert,  172 

Jones,  251 

Jones  and  Battle,  217 

Jonnesco,  191,  192 

Jouin,  194 

Julliard,  272,  280,  292,  296 

Kammeeee.  220,  221 
Kappeler.  330 
Karpetchenco,  167,  175 
Kauffman,  103,  198,  203 
Keser,  80,  162,  280 
Klebs,  65 


Koch,  103,  161 

Kocher,  109,  132,  135,  159,  189,  190, 
216,  217,  218,  219,  221,  262.  278-9, 
288,  291,  292,  293,  317,  318-20,  324, 
327 

Kohn,  74,  131,  133,  134 

Kottmann,  91,  280 

Krieg,  132.  236 

Kronlein,  115,  334 

Kummer,  217 

Kiittner,  151 

Laennec,  165 

Lange,  221 

Langeubeck,  165,  243-4 

Langton,  254 

Lannelongue,      167,    16S,    169,    170, 

175 
Larrey,  73 
Laura,  131 
Lavaran,  69 
Lebert,  131,  133 
Lediard,  16 
Leflaire,  194 
Lentz,  217 
Liebrechb,  109,  234,  241,  302,  303,  304, 

316,  329 
Lieutaud,  172 
Liouville,  131 
Lockwood,  149 
Liicke,  89 
Lugenbiibl,  IS   , 
Lustig,  68 

Maas,  220 

MacClelland,  55 

McDougall,  127 

Mackenzie,  Hector,  186,  194 

Mackenzie,  Morell,  73,  237-8 

McWhinnie,  89,  92,  241 

Madelung,  18 

Maidlow,  15 

Malgaigne,  19 

Marchant,  173 

Marsh,  98.  100,  213 

Marshall,  3,  4,  6,  7 

Maschka,  129 

Mason,  51 

Maude,  177 

Maumene.  67 

Meinert,  173 

Mikulicz,  170,  174,  275-  ) 

Mobius,  178,  187,  189 

Molliere,  130 

Montgomerie,  186 

Morean,  137 

Morris,  325 

Morton,  252 

Mosetig-Moorhof,  237 

Moxon  and  Wilks,  175 


366 


indj:x  of  names. 


MuUer,  115,  280 
Murray,  178 
Muschold,  194 


Naumann,  172 
Nelaton,  92,  94,  172 
Newman,  128 
Nicholls,  129 
Nivet,  /lO.  52,  (57 
Nussbaum,  303 


Obalinski,  234 
Odeije,  194 
Orce],  199,  217 
Ord,  186,  194,  320 
Ormsby,  15 
Oser,  174 
Osier,  78,  123-4 


Paget,  119, 133    • 
Parker,  309 
Paul,  312,  314,  315 
PaxtOD,  129 
Pean, 174 
Pearson,  150 
Perry,  147 
Petrakides,  217 
Peugniez,  192 
Peyrot,  170,  173 
Picque,  194 
Pitts,  128 
Pollosson,  19,  249 
Poncet,  245,  249,  303 
Porta,  280 
Potter,  159,  160 

QUINLAN,  147 

Kapp,  172 

Kaynaud,  94 

Eeece,  76,  159 

Eehn, 127 

Keimers,  148 

Reverdin,  A.,  119,  189,  216,  316.  323, 

334 
Eeverdin,  A.  and  J.  L.,  318-20 
Eeverdin,  J.  L.,  165,  329-31 
Eey,  128 
Eioe,  60 

Eiedel,  138,  143,  144,  145,  199 
Eobinson,  24 
Eocket,  249 

Eodocanachi,  311,  314,  315 
RoUeston,  147 

Ecse,  108,  113-14,  116,  206,  234 
Eotter,  216,  219,  221 
Eous,  304 


Rullier,  172 

Rydygier,  242,  244,  302 


St.  Lager,  50,  65,  67 

Sainsbury,  106 

Salzbach.  131 

Salzer,  174 

Samuel,  127 

Savage,  177 

Savory,  126,  309 

Schiff,  320 

Schimmelbusch,  19 

Sclmitzler,  128 

Schoenborn,  316 

Schramm,  317 

Schwalbe,  235 

Schwyzer,  221 

Seitz,  117-18,  128,  235 

Semon,  118,  139,  225,  233-4,  320 

Shattock,  206 

Shaw,  92 

Sick,  320-2 

Smith,  95,  103,  138, 139,  254 

Socin,  80,  280,  292 

Sorgo,  189 

Spencer,  185 

Starr,  188 

Stocker,  194 

Stokes,  325 

Stonham.  217 

Sulzer,  212,  217 

Symonds,  C,  150,  280 

Symonds.  H.  P.,  127 

Szumann,  317 


Tailheper,  138,  144,  145,  199 

Tait,  34 

Taylor,  C.  H.,  129 

Taylor,  E.,  34 

Teilhaber,  194 

Thomas,  94 

Tillaux,  210,  251 

Trzebickv,  276 

Turgis,  194 

Turner,  224 


Van  der  Lenden,  194 

Velpeau,  243 

Vincent,  119,  133 

Vitrac,  168,  175 

Voelcker,  147 

Von  Bergmann,  170,  174 

Von  Zoege-3Ianteuffel,  170,  174 


Wagner,  320 
Walther,  131,  241 
Webster,  16 


INDEX    OF   NAMES.  367 

Weiss,  316  Wolfenden,  74 

Wermann,  151  Wolfler.  21,  74.  78,  91,  212;  222,  241, 

Wilks  and  Moxon,  175  243 

Willcox,  126  Wolper,  174 

WiUett,  206  Woodward,  57 

Williamson,  194 

Winslow,  lOS  Zesas,  181,  320 


Printed  in-  Bai.laxtvne,  Hanson  g'  Co 
London  e~  Edinburgh 


RC655 
Berry 


B45 


Diseases  of  thp  +v 

^  tne   thyroid  gland  and 

their-  surgical  treatment. 


